Self Assessment of Radiation-Safety Programs

NCRP REPORT No. 162

SELF ASSESSMENT OF RADIATION-SAFETY PROGRAMS

National Council on Radiation Protection and Measurements

NCRP REPORT No. 162

Self Assessment of Radiation-Safety Programs

Recommendations of the NATIONAL COUNCIL ON RADIATION PROTECTION AND MEASUREMENTS

June 3, 2009

National Council on Radiation Protection and Measurements 7910 Woodmont Avenue, Suite 400 / Bethesda, MD 20814-3095

LEGAL NOTICE This Report was prepared by the National Council on Radiation Protection and Measurements (NCRP). The Council strives to provide accurate, complete and useful information in its documents. However, neither NCRP, the members of NCRP, other persons contributing to or assisting in the preparation of this Report, nor any person acting on the behalf of any of these parties: (a) makes any warranty or representation, express or implied, with respect to the accuracy, completeness or usefulness of the information contained in this Report, or that the use of any information, method or process disclosed in this Report may not infringe on privately owned rights; or (b) assumes any liability with respect to the use of, or for damages resulting from the use of any information, method or process disclosed in this Report, under the Civil Rights Act of 1964, Section 701 et seq. as amended 42 U.S.C. Section 2000e et seq. (Title VII) or any other statutory or common law theory governing liability.

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Library of Congress Cataloging-in-Publication Data National Council on Radiation Protection and Measurements. Self-assessment of radiation safety programs : recommendations of the National Council on Radiation Protection and Measurements. p. ; cm. -- (NCRP report ; no. 162) "June 3, 2009." Includes bibliographical references and index. ISBN 978-0-9823843-0-5 1. Radiology, Medical--Safety measures--Standards. 2. Radiation--Safety measures--Standards. I. National Council on Radiation Protection and Measurements. II. Series: NCRP report ; no. 162. [DNLM: 1. Radiation Protection--standards--Practice Guideline. 2. Radiation, Ionizing--Practice Guideline. 3. Professional Competence--Practice Guideline. 4. Program Evaluation--standards--Practice Guideline. 5. Safety Management-standards--Practice Guideline. WN 650 S465 2010] R895.S445 2010 616.07'5720289--dc22 2010000511

Copyright © National Council on Radiation Protection and Measurements 2010 All rights reserved. This publication is protected by copyright. No part of this publication may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotation in critical articles or reviews. [For detailed information on the availability of NCRP publications see page 103.]

Preface During the past two decades the National Council on Radiation Protection and Measurements (NCRP) has published several reports related to operational radiation safety in various occupational and medical settings, including the following reports: • No. 88, Radiation Alarms and Access Control Systems; • No. 105, Radiation Protection for Medical and Allied Health Personnel; • No. 114, Maintaining Radiation Protection Records; • No. 127, Operational Radiation Safety Program; • No. 134, Operational Radiation Safety Training; • No. 142, Operational Radiation Safety Program for Astronauts in Low-Earth Orbit: A Basic Framework; • No. 144, Radiation Protection for Particle Accelerator Facilities; • No. 145, Radiation Protection in Dentistry; • No. 147, Structural Shielding Design for Medical X-Ray Imaging Facilities; • No. 148, Radiation Protection in Veterinary Medicine; • No. 151, Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities; and • No. 157, Radiation Protection in Educational Institutions. This Report provides guidance on establishing a self-assessment program to ensure the timely self identification and correction of deficiencies in a radiation-safety program, and to improve the performance of the program by ensuring that its design and implementation are effective and efficient. Implementing the self-assessment process is an important procedure recommended for all institutions that use radioactive materials or radiation-generating devices. These institutions range from universities or research laboratories using small radioactive sources to large nuclear power plants, nuclear fuel-cycle facilities, and national government laboratories. The current Report provides guidance for individuals who have the responsibility of developing and implementing a selfassessment program at their institutions. All aspects of an effective iii

iv / PREFACE self-assessment program are described, including the identification of responsible individuals, the types and levels of self assessments to be performed, self-assessment planning and techniques, reporting of results, and the implementation and verification of corrective actions identified through a self-assessment process. In addition to supporting a safe working environment, a comprehensive selfassessment program serves to ensure regulatory compliance and conformity of operations with the goals of the radiation-safety program, to establish a workplace safety and continuous improvement culture, and to identify noteworthy practices and exemplary performance by employees working with radioactive materials and sources. This Report was prepared by Scientific Committee 2-4 on Self Assessment of Radiation-Safety Programs. Serving on the Committee were: David S. Myers, Chairman Livermore, California Members Edgar D. Bailey Pflugerville, Texas

Joel O. Lubenau Lititz, Pennsylvania

Carol D. Berger Integrated Environmental Management Inc. Gaithersburg, Maryland

John W. Luetzelschwab Dickinson College Carlisle, Pennsylvania

Mary L. Birch Charlotte, North Carolina

Kenneth L. Miller Pennsylvania State Hershey Medical Center Hershey, Pennsylvania

Susan J. Engelhardt Engelhardt and Associates, Inc. Madison, Wisconsin

John W. Poston, Sr. Texas A&M University College Station, Texas

John R. Frazier Knoxville, Tennessee

Kathryn H. Pryor Pacific Northwest National Laboratory Richland, Washington

Eric M. Goldin Southern California Edison San Clemente, California

Joshua Walkowicz Engelhardt and Associates, Inc. College Station, Texas

Kathryn A. Higley Oregon State University Corvallis, Oregon

James G. Yusko Pennsylvania Department of Environmental Protection Pittsburgh, Pennsylvania

PREFACE

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NCRP Secretariat Cindy L. O’Brien, Managing Editor David A. Schauer, Executive Director

The Council wishes to express its appreciation to the Committee members for the time and effort devoted to the preparation of this Report. NCRP is also grateful for the financial support received from the Health Physics Society during the Report preparation.

Thomas S. Tenforde President

Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii 1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 2.1 Definition of Self Assessment . . . . . . . . . . . . . . . . . . . . . . . .3 2.2 Purposes of Self Assessments . . . . . . . . . . . . . . . . . . . . . . . .4 2.2.1 Ensure a Safe Working Environment . . . . . . . . . . .5 2.2.2 Ensure Regulatory Compliance . . . . . . . . . . . . . . .5 2.2.3 Assess Conformity with the Radiation-Safety Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2.2.4 Reaffirm the Workplace Continuous Improvement Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2.2.5 Reaffirm an Atmosphere of Caring . . . . . . . . . . . . .6 2.2.6 Identify Noteworthy Practices and Exemplary Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 2.2.7 Demonstrate the Effectiveness of the Program and Identify Areas for Further Evaluation . . . . . .7 2.2.8 Provide an Opportunity for Learning . . . . . . . . . . .7 3. Types of Self Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 3.1 Performance-Based Self Assessments . . . . . . . . . . . . . . . . .8 3.2 Risk-Based Self Assessments . . . . . . . . . . . . . . . . . . . . . . .10 3.3 Compliance-Based Self Assessment . . . . . . . . . . . . . . . . . .12 3.4 Assessment Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 3.4.1 Task-Level Assessments . . . . . . . . . . . . . . . . . . . .13 3.4.2 Process-Level Assessments . . . . . . . . . . . . . . . . . .14 3.4.3 Program-Level Assessments . . . . . . . . . . . . . . . . .14 3.5 Formal or Informal Self Assessment . . . . . . . . . . . . . . . . .15 4. Responsibilities for Establishing Self-Assessment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 4.1 Upper Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 4.2 Line Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 4.3 Radiation-Safety Program Personnel . . . . . . . . . . . . . . . . .18 4.4 Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

vii

viii / CONTENTS 5. Self-Assessment Program Planning . . . . . . . . . . . . . . . . . . . 5.1 Establishing the Purpose and Objectives of the SelfAssessment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Selecting the Types of Self Assessments to be Performed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Selecting the Program Elements to be Assessed . . . . . . . 5.4 Establishing the Schedule for the Self-Assessment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Establishing the Resources for the Self-Assessment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Reviewing and Trending Self-Assessment Results . . . . . 5.7 Reviewing the Self-Assessment Program . . . . . . . . . . . . .

20 20 20 22 23 24 25 25

6. Qualification and Selection of Assessors . . . . . . . . . . . . . . 27 6.1 Assessors of Radiation-Safety Programs and Processes . 27 6.1.1 Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 6.1.2 Knowledge of Area Being Assessed . . . . . . . . . . . 28 6.1.3 Training and Certification . . . . . . . . . . . . . . . . . . 29 6.2 Assessors of Specific Radiation-Safety Tasks . . . . . . . . . . 30 6.2.1 Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 6.2.2 Knowledge of Radiation-Safety-Related Tasks . . 31 6.2.3 Training and Certification . . . . . . . . . . . . . . . . . . 31 6.3 Independence and Access to Management and Staff . . . . 31 6.4 Using In-House Personnel . . . . . . . . . . . . . . . . . . . . . . . . . 32 6.5 Self Assessments Supplemented with Outside Contractors or Independent Consultants . . . . . . . . . . . . . . . . . . . . . . . 33 7. Self-Assessment Methods and Techniques . . . . . . . . . . . . . 7.1 Evaluation of the Radiation-Monitoring Program Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Workplace Observations . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Interviews of Personnel in the Work Area . . . . . . . . . . . . 7.4 Use of Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 Document Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 Documentation of Results . . . . . . . . . . . . . . . . . . . . . . . . .

34 34 35 36 38 40 40

8. Types of Deficiencies, Response Priorities, and Noteworthy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 Identified Deficiencies that Require Routine Response . . 8.2 Identified Deficiencies that Require Timely Response . . 8.3 Identified Deficiencies that Require Prompt Response . . 8.4 Deficiencies that Require Immediate Response . . . . . . . . 8.5 Noteworthy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41 42 43 43 44 45

CONTENTS

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9. Planning an Individual Self Assessment . . . . . . . . . . . . . . .47 9.1 Schedule for an Individual Self Assessment . . . . . . . . . . .48 9.2 Task Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 9.3 Process, Program Element, and Comprehensive Program Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 9.3.1 Selecting the Focus of the Assessment . . . . . . . . .49 9.3.2 Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . .49 9.4 Responsibilities of Assessment Personnel . . . . . . . . . . . . .50 9.4.1 Team Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 9.4.2 Team Member . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 9.5 Criteria for Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . .51 9.6 Preassessment Coordination . . . . . . . . . . . . . . . . . . . . . . .52 10. Conducting the Self Assessment . . . . . . . . . . . . . . . . . . . . . .53 10.1 Entrance Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 10.2 Assessment Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 10.3 Daily Team Conferences . . . . . . . . . . . . . . . . . . . . . . . . . . .54 10.4 Management Briefings . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 10.5 Exit Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 10.6 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 11. Documenting the Self Assessment . . . . . . . . . . . . . . . . . . . . .57 11.1 Written Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 11.1.1 Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 11.1.2 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 11.1.3 Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 11.1.4 Methodology and Techniques . . . . . . . . . . . . . . . .58 11.1.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 11.1.6 Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 11.1.7 Attachments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 11.2 Communication of Results to Affected Personnel . . . . . . .61 11.3 Reports to Regulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 11.4 Note on Legal Considerations . . . . . . . . . . . . . . . . . . . . . . .61 12. Documenting Deficiencies and Corrective Actions . . . . .63 12.1 Deficiency and Corrective-Action Tracking System . . . . .63 12.1.1 Categorization of Deficiencies . . . . . . . . . . . . . . . .63 12.1.2 Regulatory Review . . . . . . . . . . . . . . . . . . . . . . . . .63 12.1.3 Causal Analysis of Deficiencies . . . . . . . . . . . . . .64 12.1.4 Isolated or Systemic Deficiencies . . . . . . . . . . . . .64 12.1.5 Development of Corrective Actions . . . . . . . . . . . .64 12.1.6 Corrective-Action Completion . . . . . . . . . . . . . . . .65 12.1.7 Evaluation of Effectiveness of Corrective Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

x / CONTENTS 12.2 Reviewing the Effectiveness of the Deficiency Tracking and Corrective-Action System . . . . . . . . . . . . . . . . . . . . . . 65 Appendix A. Interview Guide for Task Assessments . . . . . . . 67 Appendix B. Examples of Self-Assessment Lines of Inquiry B.1 Adequacy of Worker Training and Qualifications . . . . . . B.1.1 Worker Training . . . . . . . . . . . . . . . . . . . . . . . . . . B.1.2 Worker Qualifications . . . . . . . . . . . . . . . . . . . . . B.2 “As Low as Reasonably Achievable” Program . . . . . . . . . B.3 Engineered Safety Controls . . . . . . . . . . . . . . . . . . . . . . . . B.3.1 Shielding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B.3.2 Ventilation and Filtration Systems . . . . . . . . . . . B.3.3 Fume Hoods and Glove Boxes . . . . . . . . . . . . . . . B.3.4 Radiation Alarm and Access-Control Systems . . B.3.5 Air-Monitoring Equipment . . . . . . . . . . . . . . . . . B.3.6 Area-Monitoring Systems . . . . . . . . . . . . . . . . . . B.4 Adequacy of Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . B.5 Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . B.6 Radiation-Source Accountability and Control . . . . . . . . . B.7 Radiation-Safety Program Software . . . . . . . . . . . . . . . . . B.8 Worker Attitude Towards Radiation Safety . . . . . . . . . . . B.9 Environmental Radiation Protection . . . . . . . . . . . . . . . . B.10 Radioactive Waste Management . . . . . . . . . . . . . . . . . . . . B.11 Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71 71 71 72 74 76 76 77 78 78 79 80 80 82 82 84 85 85 86 87

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 The NCRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 NCRP Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

1. Executive Summary The purpose of this Report is to provide guidance for performing self assessments of radiation-safety programs. The self-assessment process is important for all institutions that use radioactive material or radiation-generating devices. These institutions range from a college using small radioactive sources in the physics department to a large nuclear power plant complex. Of course, the extent and rigor of a self-assessment program will be tailored to the size and complexity of the radiation-safety program at the institution. Self assessments are a proactive component of an effective radiation-safety program and they should occur at all levels within the institution. Self assessments can identify and correct deficiencies and can improve the performance of the radiation-safety program. The self-assessment process is designed to find and correct deficiencies before they have a negative impact on safety or the institution’s activities. Another benefit of the self-assessment program is to encourage worker involvement in improving the radiationsafety program. Finally, an effective self-assessment program can demonstrate to regulators that the risk of radiological activities is being adequately managed and that the institution is committed to safe use of radiation and radioactive material. Self assessments are planned and controlled internally by an institution. They differ from external reviews, which are generally referred to as inspections, audits or appraisals and are controlled from outside the institution, often by regulatory agencies. This Report provides guidance for individuals who have the responsibility of developing and implementing a self-assessment program at an institution. It provides information and guidance on the following topics: • definition and purposes of self assessment; • types of self assessment (i.e., performance based, risk based, compliance based, task, process and program level, formal and informal); • responsibilities for establishing self-assessment programs including upper management, line management, the radiation-safety committee (RSC), radiation-safety program personnel including the radiation-safety program manager or radiation-safety officer (RSO), and workers; 1

2 / 1. EXECUTIVE SUMMARY • self-assessment program planning for an institution including determining the purpose and type of self assessments, selecting the program elements to be assessed, allocating the necessary resources, and developing a self-assessment program review plan; • qualification and selection of individuals performing the self assessments; • self-assessment methods and techniques including evaluation of radiation-safety program survey and monitoring results, workplace observations, interviews, document reviews, checklists, review of metrics, and questionnaires; • types of deficiencies that can be identified in the self-assessment process, ranging from the minor ones that are most likely to be found to those that are more serious; • identification of noteworthy practices; • planning an individual self assessment including the program elements to be assessed, the schedule for performing the self assessment, and the type(s) of self assessment to be used; • conducting the self assessment including the entrance meeting, performing the assessment activities, daily team conferences, upper management briefings, exit meeting, and documentation; • documenting the self assessment including writing reports, report approval, communicating the results, and legal considerations; and • developing corrective-action plans including tracking and resolution of corrective actions and reviewing the effectiveness of the corrective-action program.

2. Introduction 2.1 Definition of Self Assessment The National Council on Radiation Protection and Measurements (NCRP, 1998) described a radiation-safety program audit as “a deliberate examination of the program to determine if it is effective.” Deliberate examinations of a radiation-safety program that are planned and controlled internally by an institution are referred to as self assessments. In this Report, an institution refers to a management structure and its associated activities conducted in one or more facilities at one or more sites. Examples of institutions include a corporation in the private sector, a government research laboratory, a hospital, a nuclear power plant or other nuclear fuelcycle facility, and a university. Specifically, self assessment is the process that an institution uses to critically review its own activities and performance in relation to regulations, standards, internal policy documents, implementing procedures, industry best practices, and goals. In the selfassessment process, the institution determines who will perform the assessment, what radiation-safety program areas will be assessed, and the schedule for the assessment. The institution also controls how and to whom the results are reported. Generally, self-assessment results are maintained internal to the institution. In some cases, the results of the self assessments may be disseminated to regulators and others outside the institution who may benefit from them. The elements of the self-assessment process include: • establishing an overall self-assessment program plan; • assigning responsibilities for implementing the self-assessment program; • identifying the purpose of the self assessment; • identifying the type of self assessment to be performed (i.e., performance, risk and compliance based); • identifying the level of the self assessment (i.e., task, process and program); • determining whether the self assessment will be formal or informal; 3

4 / 2. INTRODUCTION • identifying qualified individuals to conduct the self assessment; • reviewing specific self-assessment methods and techniques (e.g., interviews, checklists, observations, document reviews, review of performance measure results); • developing an individual self-assessment plan (e.g., areas to be assessed, criteria used for assessment, level of self assessment); • conducting the self assessment; • documenting and reporting the results of the self assessment; • determining the causes of any deficiencies; • developing corrective actions; and • implementing and verifying the implementation and effectiveness of corrective actions. Each of these elements of the self-assessment process is discussed in detail in this Report. Self assessments are proactive components of effective radiation-safety program management plans. Self assessments can and should occur at all levels within the institution and they have the potential of engaging everyone as stakeholders in improving the radiation-safety program. Self assessment is an effective tool to evaluate new program elements, new or changed radiological activities, and changes in requirements or regulations. Self assessments do not include reviews conducted and controlled by individuals external to the institution being assessed. These external reviews are generally referred to as inspections, audits or appraisals. Also, routine renewals of work authorizations that may include a review of hazards, controls and performance are typically not considered part of the self-assessment process. Finally, since self assessments are prospective evaluations of an institution’s radiation-safety program, they do not include incident or accident investigations, which are retrospective in nature and have their own formal methodology. For example, the U.S. Department of Energy (DOE, 1997) and the U.S. Nuclear Regulatory Commission (NRC, 1997) provide guidance for performing accident investigations. 2.2 Purposes of Self Assessments The self-assessment process has two general objectives. The first is the timely self identification and correction of deficiencies or weaknesses in the radiation-safety program. The second is to

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improve the performance of the radiation-safety program by ensuring that its design, development and implementation are effective and efficient. The specific purposes of a self assessment are discussed in the following paragraphs. 2.2.1

Ensure a Safe Working Environment

One of the most important purposes of a self-assessment program is to identify and correct deficiencies in the radiation-safety program. These deficiencies include unsafe practices, equipment, and working conditions that could lead to incidents and accidents and radiation exposures that are either not as low as reasonably achievable (ALARA) (NCRP, 1998) or over regulatory limits. Examples of the types of deficiencies and severity levels are presented in Section 8. Self assessments can help eliminate or minimize the possibility of accidents and minimize the impact when accidents occur. Self assessments can help ensure that procedure changes do not inadvertently lessen the established level of safety. In addition to ensuring a safe working environment, self assessments can help ensure the safety of the public and the protection of the environment. 2.2.2

Ensure Regulatory Compliance

All radiation-safety programs must comply with applicable regulations and license conditions. NRC and its Agreement States, DOE, U.S. Environmental Protection Agency (EPA), Occupational Safety and Health Administration (OSHA), U.S. Food and Drug Administration (FDA), U.S. Department of Transportation (DOT), Mine Safety and Health Administration (MSHA), and other government agencies issue regulations that may be applicable to a radiation-safety program. Also, states have the authority for regulating the use of accelerators and x-ray machines not covered by federal regulations. All regulations require that radiation exposures be within regulatory limits. NRC and its Agreement States, DOE, EPA, FDA, and the states (for accelerators and x-ray machines) also require that radiation exposures comply with the ALARA principle. The requirements of applicable regulations must be incorporated into top-level policy documents and implemented through procedures, manuals and work documents. A compliance-based self assessment (Section 3.3) can help evaluate how well the radiation-safety program complies with the applicable regulatory requirements. The purposes of this type of

6 / 2. INTRODUCTION self assessment are to enhance safety and to identify instances of noncompliance so that preemptive corrective actions can be taken. 2.2.3

Assess Conformity with the Radiation-Safety Program

In addition to the regulations, the day-to-day radiation-safety program is based on standards, internal policy documents and manuals, implementing procedures, and goals. It is important to assess whether operations are conducted in conformance with these implementing documents. It is also important to identify areas of the radiation-safety program with insufficient or inadequate implementing guidance. 2.2.4

Reaffirm the Workplace Continuous Improvement Culture

Aggressive self assessments can identify opportunities for improvement, including identification of practices that hinder quality improvement, beyond findings of noncompliance. Self assessments can also foster a workplace safety culture that encourages the adoption of best available technology or standards-ofpractice and the identification and elimination of nonvalue added activities. There are a number of management initiatives such as the Baldrige National Quality Program (NIST, 1987), various implementations of total quality management including the International Organization for Standardization standard (ISO, 2008), and the DOE Integrated Safety Management Program (DOE, 2006) that advocate a culture of continuous improvement. Also, NRC (2005) has provided guidance for establishing and maintaining a safety conscious work environment and the International Atomic Energy Agency (IAEA, 2002) has provided guidance in enhancing a safety culture in nuclear facilities. A culture of continuous improvement is one in which workers are empowered by management to identify and make small changes to processes that result in continuous improvement over time. One method of identifying these small changes is by workers and supervisors conducting self assessments of workplace tasks and processes that they use every day. 2.2.5

Reaffirm an Atmosphere of Caring

Self assessments are one opportunity to let employees know they have ready access to their supervisors, the radiation-safety staff, and management. They can serve to reemphasize to staff that they have access to various services and that management is concerned with their well-being.

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When employees are empowered to assure their own safety through active participation in self-assessment programs, it can increase their desire to perform their tasks in a better way rather than simply because they are told to do so or to comply with regulations. In order to foster openness during the self-assessment process, self-critical assessments should be encouraged. The emphasis should be focused on process improvements as opposed to finding fault with personal performance. If the self assessment reveals instances of deliberate or negligent actions by employees, these cases should be referred to management for appropriate action. 2.2.6

Identify Noteworthy Practices and Exemplary Performance

In addition to identifying deficiencies in a radiation-safety program, self assessments can help identify noteworthy practices that can be implemented in other program areas as part of a continuous improvement program. Also, self assessments should identify exemplary performance so that the workers can be acknowledged for their efforts. Specific examples of noteworthy practices are presented in Section 8. 2.2.7

Demonstrate the Effectiveness of the Program and Identify Areas for Further Evaluation

Self assessment can identify program strengths and systemic weaknesses. Self assessments can help drive strategic decisions about the direction of the program, including priorities, resources, and improvement initiatives. Assessment serves to evaluate overall performance of the program, and provides a method for reporting to stakeholders (e.g., senior management, regulators, and workers). Weaknesses and vulnerabilities may warrant further oversight and management attention. A single condition can indicate a systemic weakness that can only be determined through evaluation of the extent of the condition. In certain cases, follow-up assessment may be warranted. 2.2.8

Provide an Opportunity for Learning

Assessors themselves have the opportunity to learn new elements of the radiation-safety program when they participate in self assessments. This approach can improve interfaces during normal and emergency radiation-protection activities. Peer-to-peer assessment can facilitate the cross-pollination of good practices and increases consistency across a program as appropriate.

3. Types of Self Assessment The primary purpose of a radiation-safety program is to maintain radiation exposures to employees and the public within regulatory limits including a requirement that exposures be maintained ALARA (NCRP, 1998). There are three primary types of self assessment used to assess whether a radiation-safety program is achieving this purpose. They are performance-, risk-, and compliance-based self assessments. Self assessments also vary based on the level at which the assessment occurs (task, process or program) and on the degree of desired formality and rigor. While each primary type is described separately, elements of each may be used, especially when conducting a comprehensive self assessment of a large radiation-safety program. Each type may be used to assess specific aspects of a radiation-safety program element in one or across multiple line organizations in a horizontal slice. The assessment types may also be combined to review radiation safety in a particular line organization in a vertical slice such as waste management or operations in a particular laboratory. The types of self assessment are discussed in the following paragraphs. 3.1 Performance-Based Self Assessments As defined in this Report, a performance-based self assessment evaluates the overall effectiveness and efficiency of a radiation-safety program. That is, in addition to evaluating compliance with regulations, it takes a broad look at the radiation-safety program (or an element of a radiation-safety program) to assess how well it is performing. This could include assessing how well the ALARA program is implemented, the adequacy of and adherence to internal procedures, the ability to respond to emergencies, the quality and implementation of radiation-safety training, ongoing efforts to improve the radiation-safety program, the quality of the radiation staff and the guidance they provide, and management commitment to and involvement in the radiation-safety program. In summary, a performance-based self assessment evaluates the effectiveness of the radiation-safety program beyond just compliance with regulations. 8

3.1 PERFORMANCE-BASED SELF ASSESSMENTS

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Specific questions that could be asked in a performance-based assessment concerning radiation-safety program performance include: • Has there been a history of significant incidents or accidents resulting in overexposure to workers or the public? • Do occupational radiation doses to workers meet regulatory requirements including ALARA? • Have there been instances of procedural violations or lack of procedural guidance? • Do releases of equipment, property, and radioactive material to the environment or other public exposure pathways meet regulatory requirements including ALARA? • Have performance measures been established and are they being met? • Are incidents and emergencies responded to properly? • Are emergency-response exercises executed properly? • Have there been any near misses? • Have there been any instances of misplaced, lost or stolen radioactive materials or sources, or radiation-generating devices? • Do radiation measurements (e.g., personal dosimeters, surveys, air samples, swipes) provide appropriate information to the required levels of sensitivity and accuracy? • Do engineered controls function as designed? • Is personal protective equipment (PPE) specified, appropriate, available, in good condition, and utilized properly? Questions concerning radiation-safety program management: • Are funding, staffing, and staff qualifications adequate for the radiation-safety program? • Is adequate training provided so workers can effectively perform their radiation-safety program responsibilities? • Is management actively involved in evaluating the performance of the radiation-safety program? • Are radiation-safety program performance goals being met? • Does management encourage a safety culture and consider safety in performance reviews of staff members? • Do management and staff act as a team to implement the radiation-safety program? • Are resources dedicated to implement corrective actions when deficiencies are identified?

10 / 3. TYPES OF SELF ASSESSMENT • Does management provide the radiation-safety staff sufficient authority and independence to implement the radiation-safety program? • Is management committed to the continuous improvement of the radiation-safety program? While an assessor must be familiar with regulations and institutional requirements, in performance-based assessments the assessor’s knowledge and experience are essential factors in determining whether the radiation-safety program is performing satisfactorily. Therefore, participants in performance-based assessments must be technically competent in the areas they are assessing. For example, an assessor evaluating a waste management process must be familiar with the potential hazards within the process, waste classification and waste-form requirements; transportation regulations including appropriate packaging, labeling and shielding requirements; and any regulatory guidance from oversight agencies. In addition, it would be very desirable for the assessor to be familiar with other regulations such as security, criticality safety, chemical safety, industrial safety, and industrial hygiene that could impact the radiation-safety program. The performance-based assessment usually provides the most useful information to management; however, it requires a high level of competence on the part of the assessment team. 3.2 Risk-Based Self Assessments In this Report, a risk-based self assessment is the evaluation of the radiation-safety program to determine if the radiological risks have been reduced to those deemed acceptable by the institution. These risks could be health risks to workers, the public, or the environment. In addition to the potential health risks of a radiological incident or condition, the potential financial costs of suspending operations, mitigation efforts, adverse public perception, regulatory fines and impacts, and the negative impact on business should be considered. A risk assessment considers both the consequences of a hazardous incident and the probability that the incident could occur. The radiation-safety program should be designed and implemented to reduce the radiological risk from primary program activities (e.g., nuclear power plant, nuclear-medicine laboratory, particle accelerator) to an acceptable level. If the radiation-safety program is not properly designed or executed, it can result in unacceptable risks to workers, the public, or the environment. For example, the improper

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analysis of the contents of a waste-retention tank could result in a significant release to the environment or the improper use of a survey instrument could lead to worker overexposure. Guidance on performing in-depth risk assessments is available in Vesely et al. (1981). In a risk-based self assessment, the questions that should be asked are, “What could go wrong?” and “Have mitigating measures been put in place to keep the risk at acceptable levels if something does go wrong?” It is important that senior management establish expectations and standards for acceptable risk, based on regulatory and other stakeholder considerations. Specific questions that should be asked in a risk-based assessment are: • Has the staff identified the potential hazards and determined the probability that hazardous incidents could occur for the various radiological operations? For example: have the risks from a failure of a piece of safety equipment, failure to follow a procedure, or the failure to respond properly in an emergency been identified and adequate backup measures been implemented? Specific examples include the following: - If failure of a single interlock could lead to a high hazard situation, have two interlocks in series been installed or have other hazard mitigating measures been implemented? - If breach of a filter on a hazardous effluent stack could produce a significant risk to the public, have multiple filters and a filter protection system been provided? - If failure of a radiation survey instrument could lead to a significant hazard to workers, what procedures have been implemented to minimize this possibility, and what backup radiation-monitoring techniques have been implemented? - If failure to follow a safety procedure could lead to a significant hazard to workers, is there a double check or independent verification built into the procedure to enhance the likelihood that the procedure is followed properly? - If the loss of control of a radioactive source could present a significant risk to workers or the public, have adequate controls been implemented to secure the source during storage, transport, change of custody, and handling activities?

12 / 3. TYPES OF SELF ASSESSMENT • Is there a proper balance between the use of engineered controls and administrative controls? • Are incidents and near misses evaluated and follow-up actions taken to minimize the possibility of their recurrence? • Is there an adequate emergency-response program to reduce the consequences from incidents to acceptable levels? If a high-consequence accident is credible, are there sufficient procedures, training plans, and emergency exercise protocols in place? • Are workers trained adequately to reduce the risk from radiation-safety program-related activities to acceptable levels? • Are resources, staffing and priorities allocated based on risk? • Has the ALARA principle been incorporated into operations? The specific radiological risk will depend on the specific program activity. However, the level of acceptable risk should be consistent throughout an organization. The objective of a risk-based self assessment is to ensure that radiological risks have been identified and mitigating controls have been implemented to reduce the risks to an acceptable level. 3.3 Compliance-Based Self Assessment Stalnaker (1996) describes self assessments as an effective way for a safety program to achieve a level of performance that can withstand external scrutiny. All radiological protection programs must satisfy applicable regulatory requirements and license or permit conditions. The regulations that apply to a radiation-safety program are determined by the type of operation; the size, complexity and potential radiological hazards associated with a program; and the regulatory agency that has jurisdiction. As noted in Section 2.2.2, the regulations are issued by NRC and its Agreement States, the states (for accelerators and x-ray machines), DOE, EPA, OSHA, FDA, DOT, MSHA, and other government agencies. These requirements should be incorporated in top-level policy documents and reflected in implementing procedures. As defined in this Report, a compliance-based self assessment evaluates whether a radiation-safety program complies with regulatory requirements and license or permit conditions. This process first requires the identification of the applicable radiation-safety regulations including license requirements. Next, it requires a review of the radiation-safety program to evaluate whether all regulations and other external requirements (e.g., contractual,

3.4 ASSESSMENT LEVELS

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permits, registrations) are being met. Since a compliance-based self assessment focuses solely on compliance with regulations, it is typically less comprehensive than a performance-based assessment (Section 3.1) and may not be a valid assessment of the overall safety program. Finally, there should be a process in place to bring the program into compliance with new regulatory requirements. This can be a particularly challenging process when an institution has facilities at more than one site and involves different state regulatory agencies. 3.4 Assessment Levels Self assessments can be performed at the task, process or program level. The level of assessment depends on management support for the self-assessment process, the culture or institutional attitude toward continuous improvement, and on the experience of workers. The more receptive the institution is to continuous improvement, the more advantageous it is to perform self assessments at the task level. The more experienced the work force, the more likely work units or teams can perform assessments of their work processes and tasks with a reduced need for specialized assessors. 3.4.1

Task-Level Assessments

A task is a work activity that has a definite beginning and ending, consists of two or more steps, and leads to a product, service or decision. Examples include: • entering radioactive material into a glove box; • placement and wearing of external dosimeters; • surveying when workers exit potentially-contaminated areas; and • labeling of radioactive-waste containers. Task-level assessments examine work controls and verify that the work controls are being implemented effectively. Task-level assessments are often called “job observations.” Typically, a single assessor performs a task-level assessment. Depending on the knowledge and experience of the assessor, the assessment can simply verify compliance with written procedures. If a more experienced assessor conducts the assessment, the assessor may ensure that all work controls were implemented during a specific task to control the associated hazards or look for opportunities for improvement of task performance. Such “floor-level”

14 / 3. TYPES OF SELF ASSESSMENT assessments should include evaluation of other workplace hazards and controls if practicable, and they are an opportunity for open conversation about individual concerns and program issues. 3.4.2

Process-Level Assessments

A process is a series of actions that are taken to achieve a desired result and usually will include multiple tasks. Examples of processes are: • management of radioactive materials in a glove-box environment (entry, removal, inventory and handling techniques); • issuance, retrieval and processing of external dosimeters; • egress of a worker from a contaminated area to an uncontaminated area; and • radioactive-waste storage and/or shipment. The process-level assessment focuses on whether the component tasks and procedures are appropriate, the performance objectives are being met, and whether the process complies with the appropriate regulations and requirements. The process-level assessment also reviews management’s commitment to providing the appropriate leadership and support systems to implement the processes. For example: • Are adequate resources provided for external dosimeters and dosimeter processing equipment? • Is proper equipment for surveying workers and checking for contamination in the workplace available and in use? • Is there an adequate radioactive-waste storage area and is adequate waste monitoring equipment provided? • Do personnel receive adequate training, including basic radiation concepts, regulations, the use of radiation survey instrumentation, and the radiation-safety procedures used at the institution? 3.4.3

Program-Level Assessments

A program is the integration of a set of processes and other activities that are planned, initiated and managed in a coordinated way to achieve desired results. Program-level assessments are very important because they address primary elements of the radiation-safety program and because problems can occur in handoffs/connections between processes within a program. Examples of program-level assessments are:

3.5 FORMAL OR INFORMAL SELF ASSESSMENT

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• glove-box operations, including management of materials, ventilation and filtration, fire protection, maintenance, and emergency power; • external radiation dosimetry program; • contamination control program; • radioactive waste-management program; • PPE program, including the proper use of respiratory protection; and • sealed-source safety and security program including receipt, use, inventory, storage and disposal. The conduct of program-level assessments can answer the following questions: • Are the radiation-safety program components properly established and implemented? • Are the elements that establish the radiation-safety program adequately integrated? • Are the appropriate leadership and support systems provided to enable the implementation of the programs? • Are changes in programmatic operations adequately evaluated and appropriate safety controls implemented? A specific example of a program-level assessment is the review of a researcher’s new use of radioactive materials or radiationgenerating device to ensure that hazards are adequately addressed and any process changes are evaluated. Another example is an assessment after a change in regulatory requirements to ensure that the requirements are addressed by all program elements. Because of their scope and complexity, a team typically conducts program-level assessments. Program-level assessments generally have formal assessment criteria, are characterized by their thoroughness, and are often performed on a regular frequency. 3.5 Formal or Informal Self Assessment In general, the degree of formality and rigor of a self-assessment program should be based on the degree of risk associated with the radiological activities and the size and complexity of the radiationsafety program. For example, the self assessment of the radiation-safety program for a nuclear power plant will be very formal and very rigorous; that for a small campus laboratory using only small check sources much less so. Typically, formal self assessments are highly structured and have well-defined assessment criteria. Formal self assessments can

16 / 3. TYPES OF SELF ASSESSMENT be initiated internally to address questions discussed in Sections 3.1 to 3.3, performed as a good practice, may be an element of an institution-wide assessment program, or they may be required by regulations. Formal self assessments should be performed periodically on all functional areas of the radiation-safety program. As a general rule, program- and process-level assessments are formal in nature. Informal self assessments are by definition less rigorous than formal self assessments. They can be performed by managers or supervisors to familiarize themselves with an aspect of the radiation-safety program, to evaluate a question or concern raised by an employee, or to review a new radiological activity or minor program change. Task-level assessments are typically informal in nature. Workers can also provide input to the self-assessment process based on their work experiences. An effective radiation-safety program involves regular feedback from workers based on their experiences working directly with the radiation source. When faced with potential radiation hazards that they feel are not adequately addressed, workers should communicate the problem to their supervisor or a radiation-safety staff member. Often the workers themselves can offer effective suggestions to eliminate the hazard or reduce it to an acceptable level. All self assessments should be documented. A formal self assessment should be documented in a comprehensive report commensurate with the length and complexity of the assessment. An informal self assessment might be documented in a supervisor’s logbook. More information about documenting self assessments is provided in Section 11. Finally, it is absolutely essential that any findings of serious or imminently dangerous safety situations as defined in Section 8 be resolved with appropriate urgency regardless of the means of identification. Severe and imminent threats typically require that, at a minimum, the activity be stopped and that management be notified immediately.

4. Responsibilities for Establishing SelfAssessment Programs 4.1 Upper Management Institutional managers are responsible for providing a safe workplace and for promoting a safety culture among all workers. A selfassessment program is an important tool for fulfilling this responsibility. Thus, it is important that upper management of an institution understands and appreciates the goals and benefits of self-assessment programs. As discussed in Section 2.2, one of the most important purposes of self-assessment programs is to enhance the health and safety of workers and the public and to protect the environment. Another benefit of self-assessment programs is to ensure that the institution is in compliance with all applicable laws and regulations regarding protection of workers, members of the public, and the environment. An effective self-assessment program will facilitate the continuous improvement of a radiation-safety program. Several federal regulatory agencies, including DOE (2008a), EPA (2000), NRC (2008a; 2008b), and OSHA (2000) and many state and local agencies either require or highly recommend self assessments as a part of their regulatory framework. In some cases, the regulatory agency will refrain from issuing a citation or lessen a penalty for violations that have been identified through a selfassessment program provided the violation has been corrected and appropriate steps have been taken to prevent its recurrence. The regulatory agency may also require self reporting of the violation. Therefore, it is important that upper management strongly and visibly support an institution’s self-assessment program by providing the necessary resources of adequately trained assessors, time, and equipment to conduct the self-assessment program and to promptly correct violations or other deficiencies that are identified. Although upper management is responsible for sponsoring the selfassessment program, radiation-safety program personnel are typically tasked with planning and conducting the self assessments. Upper management should also ensure that the findings of the self-assessment program are brought directly to them for their information and, as appropriate, follow-up action. 17

18 / 4. ESTABLISHING SELF-ASSESSMENT PROGRAMS 4.2 Line Management Line managers have the responsibility to understand and support the purposes of self assessments and the potential benefits to their operational units. They should understand that it is not the purpose of the self-assessment program to find fault or fix blame, but rather to aid in the early identification and correction of deficiencies and to improve processes so they run more safely and efficiently. In addition, line mangers should: • be familiar with the procedures that are used in the development and execution of self assessments (line managers often have primary responsibility for participating in assessments and for executing corrective actions for their areas of responsibility); • ensure that those they supervise are encouraged and afforded the opportunity to participate in the development of self-assessment plans (e.g., the development of checklists); and • encourage those they supervise to participate in the selfassessment process and ensure that they participate fully without any fear of recrimination for their participation and input. 4.3 Radiation-Safety Program Personnel Typically, the radiation-safety program manager or the RSO has the responsibility for developing, implementing and maintaining the self-assessment program. NCRP (1998) specified that auditing the effectiveness of a radiation-safety program is a responsibility of the radiation-safety advisory organization. At many institutions, a RSC provides oversight for the radiationsafety program and would provide input to the planning of the self-assessment plan. Elements of the self-assessment program (e.g., conducting the self assessment, compiling the findings, and preparing the selfassessment report) are often delegated to radiation-safety staff members. Guidance on developing a self-assessment program plan is provided in Section 5. Guidance on developing individual selfassessment plans is provided in Section 9. Guidance on preparing the self-assessment report is provided in Section 11 of this Report. With input from workers and managers, radiation-safety program personnel should develop self-assessment tools specific to the institution they are assessing. Guidance on specific self-assessment methods and techniques is provided in Section 7 of this Report.

4.4 WORKERS

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Radiation-safety program personnel (or management) should communicate the results of the self assessment and identify corrective actions that have been taken or are planned. Lessons learned from the self assessment should be communicated to the remainder of the institution. Radiation-safety personnel often have responsibility for implementing corrective actions in response to assessment findings. 4.4 Workers As discussed in Section 4.1, managers and supervisors are responsible for providing a safe workplace. However, as stated in NCRP (1998), ultimately workers are responsible for their own safety. It is important that workers understand the self-assessment program and process and the benefits that are associated with it. This understanding will require that workers be informed about the self-assessment program through meetings, training classes, and/or written material, as appropriate. Individuals who are given privileges to use radioactive material or radiation-generating equipment have a responsibility to perform self assessments of their work areas and activities. They should periodically review handling procedures and techniques and whether they are following good safety practices. This will help to ensure that everyone using radiation sources is working in a safe manner and not placing their privileges in jeopardy. Individuals may occasionally request an independent assessment of their work areas. A member of the radiation-safety staff could perform such an assessment. Workers may be given the responsibility to perform task and process-level self assessments and they may be asked by management to participate in the development and implementation of the self-assessment program. It is important that each worker fulfill the self-assessment responsibilities to which he or she is assigned. Workers should understand that only by their full participation in the self-assessment program can the full potential of the program be realized. Finally, as discussed in Section 3.5, an effective radiation-safety program involves feedback from workers on a regular basis. Workers should communicate any concerns regarding radiation safety to their supervisor or a radiation-safety staff member. Often the workers can offer useful suggestions to eliminate a hazard or reduce it to an acceptable level.

5. Self-Assessment Program Planning An individual self assessment is generally performed within the framework of an overall self-assessment program. Frequently, in larger institutions, the radiation-safety self-assessment program is likely to be part of an institution-wide performance improvement program that addresses a wide variety of topics such as operations, maintenance, training, and other safety disciplines. Management should require the self-assessment program plan to be comprehensive and that individual assessments are organized and conducted in a cost-effective, efficient manner. Institutional management, the radiation-safety staff, a quality-assurance organization, or a combination thereof can establish a self-assessment program. Self-assessment program plans should be developed to the level of rigor and detail necessary to ensure adequate review of the radiation-safety program being assessed. Smaller institutions will generally have smaller scope radiation-safety programs, and selfassessment program planning will likewise be less complex. This section discusses factors that should be considered in developing a self-assessment program plan. Guidance for planning individual self assessments is provided in Section 9 of this Report. 5.1 Establish the Purpose and Objectives of the Self-Assessment Program The purposes for performing self assessments are discussed in Section 2.2. In preparing a self-assessment program plan, Section 2.2 should be reviewed to aid in determining the overall objectives of the self-assessment program. In general, a self-assessment program will include most or all of the objectives listed in Section 2.2, but program planners may choose to focus on one or more of the objectives based on past experience and/or plans for improving the radiation-safety program. The objectives of the self-assessment program should be documented in the program plan. 5.2 Selecting the Types of Self Assessments to be Performed Program planners should review the types and levels of self assessments discussed in Section 3 of this Report. Although an 20

5.2 SELECTING THE TYPES OF SELF ASSESSMENTS

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individual self assessment might emphasize a specific assessment type (i.e., performance, risk or compliance based), a self assessment typically includes elements of more than one assessment type. For example, a performance-based self assessment could identify that the contents of a waste-retention tank were being improperly analyzed. Then a compliance-based assessment would be used to determine if the release of the contents of the wasteretention tank was above regulatory limits. Regardless of assessment type used, they all have the same purpose, which is to improve the radiation-safety program as discussed in Section 2.2. The specific mix of self-assessment types selected would normally be a function of the institution and the purposes of the selfassessment program that were identified in Section 5.1. Using a mix of self-assessment types will likely provide the most comprehensive evaluation of the overall performance of a radiation-safety program. Typically, a combination of short-term and in-depth program, process, and task-level self assessments will provide a good overview of the radiation-safety program. Task-level assessments might consist of radiation-safety staff members or first-line supervisors observing a task or activity being performed by healthphysics technicians or radiation workers, while a process-level assessment might examine a radiological work process performed by a team of radiation workers. A program-level assessment might be an assessment in a specific topical area, such as the implementation of regulatory requirements for an internal dosimetry program. Also, the implementation of the radiation-safety program by a specific line organization, such as a maintenance department, could also be examined using performance-, risk- and compliancebased assessment techniques. Choosing the type of self assessment for an individual self assessment should consider several factors, which are contained in the following list. Suggested assessment types are given in parentheses after each factor, although the actual assessment type (or mix of types) will depend on the specific circumstances. • Is it a regularly scheduled self assessment? (performance, risk, compliance) • Have there been incidents involving unnecessary radiation exposure to workers? (performance, compliance) • Have there been an unusual number of contamination incidents or loss of control of radioactive material? (performance) • Have there been an unusual number of near misses that could have resulted in a radiological incident or accident? (performance, risk)

22 / 5. SELF-ASSESSMENT PROGRAM PLANNING • Has there been an increase in noncompliance citations by a regulatory agency or is a compliance inspection scheduled for the near future? (compliance) • Have the radiological risks been adequately assessed by the radiation-safety program? (risk) • Have workers expressed concerns about a potential radiation hazard that in their view is not adequately addressed by the radiation-safety program? (performance, risk) • Has the workload increased significantly since the last self assessment? (performance, risk) • Is there a new or changed process, radiological operation, or requirement? (performance, risk, compliance) • Is there a known or suspected vulnerability at a specific facility or within a process that warrants a review? (risk) • Is there a corrective action or process improvement that warrants effectiveness evaluation? (performance) • Are there specific performance issues identified by previous assessments, events, performance indicators, management, or regulators that warrant focused assessment? (performance) 5.3 Selecting the Program Elements to be Assessed A radiation-safety program consists of program elements that are dependent on the extent and complexity of the radiological activities at the institution. The self-assessment program plan should determine the set of program elements that need to be included in the self-assessment program and should be comprehensive in nature. The following is a list of radiation-safety program elements that may be applicable to the radiation-safety program at a specific institution: • • • • • • • • • •

radiation-safety program management/leadership; ALARA program; internal/external radiation dosimetry programs; radiation-safety training program; radiological-survey program; radiological-instrumentation program; radioactive-material receipt and shipment program; solid and liquid radioactive waste-control program; effluent release and environmental-monitoring program; engineered safety-control program, including radiationshielding design and configuration control; • radiological work planning and control program;

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• contamination control, including hot-particle control program; • radioactive-material/source security, accountability and control program; • emergency-response program; • radiation-generating device program; • radiological posting and labeling; • PPE program, including the proper use of respiratory protection; • medical x-ray/nuclear-imaging program; • radiation therapy program; • document control and record retention program; • RSO and RSC responsibilities; • regulatory compliance program, including licensing and permits; and • facility design and maintenance. Once the appropriate assessment topics have been identified, they should be prioritized. Priority should be given to those program elements which are identified as having the highest risk, their past performance was less than adequate, or there have been significant changes in the program. Program areas having the highest risk can be identified through review of performance indicator data, previous assessment results, worker feedback, near misses, etc. It is also useful to review industry lessons learned or known regulatory agency or external assessor focus areas. In addition to the risk of radiological consequences of failure, the risk of adverse public perception, and operational or regulatory/compliance impacts should be considered. 5.4 Establishing the Schedule for the Self-Assessment Program Self-assessment plans should be developed to cover a logical time interval. The time interval could be annual as required by NRC (2008a), or some longer cycle [e.g., 3 y, as required by DOE (2008a) and NRC (2008c)]. In general, self assessments should be conducted at frequencies commensurate with the hazards involved. The overall schedule and frequency of self assessments is generally determined by institutional management. All program elements in the radiation-safety program should be examined during the self-assessment cycle. Small programs may cover all program elements in a single assessment or a single year. Larger programs will generally require a longer assessment cycle

24 / 5. SELF-ASSESSMENT PROGRAM PLANNING (e.g., up to 3 y) to examine all program elements in sufficient detail. Regulatory requirements (e.g., NRC, 2008a) for an annual review of a radiation-safety program can generally be satisfied by a comprehensive self-assessment program. The self-assessment program schedule should allow adequate time for preparation, performance (including document reviews and field work), analysis, and documentation of results. With demonstrated positive performance in a given program area, the frequency and/or duration of self assessments in specific program elements may be decreased. Job observations or assessments of individual or multiple tasks should occur more frequently than process or program element assessments because these assessments have the potential to reduce individual exposures or intakes of radioactive material. Emphasizing task-level assessments helps ensure that appropriate attention is focused on day-to-day safe conduct of work. Processes are typically assessed more frequently than program elements but less frequently than job observations to ensure that the appropriate requirements and safety precautions are addressed and that processes are achieving their intended purposes. To summarize, the frequency for conducting individual self assessments depends on the program self-assessment cycle, the type of institution, the frequency at which certain tasks and processes are performed, deficiencies found during prior self assessments, the safety performance of the institution, and the desires and expectations of management. The frequency should be documented in the self-assessment program plan. 5.5 Establishing the Resources for the Self-Assessment Program When planning the self-assessment program, it is important to make sure that adequate resources are available to meet the established assessment schedule. Self assessments can be performed by in-house staff, and potentially supplemented by outside personnel, including consultants or assessors available under reciprocal arrangements with other institutions. There is some benefit to mixing the use of in-house staff and outside personnel to provide familiarity with internal operations and an independent look at radiation-safety program elements. Similarly, self assessments may be conducted by the line or facility organizations, radiation-safety staff, or a combination of the three. If the line or facility organizations perform self assessments, they are more likely to take ownership of their performance in implementing the radiation-safety program. If radiation-safety staff members perform self assessments, they can provide in-depth

5.7 REVIEWING THE SELF-ASSESSMENT PROGRAM

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subject matter expertise in the functional program elements being assessed. In many cases, a cross-functional team can be used to provide both the subject matter expertise and operational viewpoints. However, when an assessor has direct responsibility for program or regulatory compliance in the area being assessed, consideration should be given for the need to be self critical. The training and qualifications of the self-assessment staff are discussed in Section 6. 5.6 Reviewing and Trending Self-Assessment Results Self-assessment results should be collectively reviewed to provide a picture of overall performance of the radiation-safety program. One useful tool in determining if the self-assessment program is meeting its intended objectives is the development and ongoing review of performance measures. Trending of performance measures provides useful analytical information for determining both the effectiveness of the performance improvement process or declining performance in a specific program area. This allows management to focus resources on problem areas that could lead to significant incidents. Examples of performance measures include: • average and collective occupational dose; • number of contamination incidents; • number of medical x rays that have to be repeated because of an error in technique; • number of personnel exposures exceeding regulatory or administrative limits; and • number of radiation survey instruments not calibrated at required intervals. The collective review and analysis of self-assessment results and performance trends should be documented in periodic reports. These reports should clearly identify both areas of positive performance improvements and any areas in which performance is declining and need additional resources or focus. One of the key indicators for self assessment effectiveness is the frequency of repeated deficiencies. If these are occurring in a specific program element, management should identify the underlying causes of declining performance, and develop corrective actions to improve that performance (see Section12.1.3 for guidance in performing a causal analysis for deficiencies). 5.7 Reviewing the Self-Assessment Program The self-assessment program itself should be reviewed periodically to ensure that it is providing value and meeting its objectives.

26 / 5. SELF-ASSESSMENT PROGRAM PLANNING Management should periodically review the overall self-assessment program to ensure that it is both useful and effective. Effectiveness reviews should examine whether areas for improvement are being identified, real performance improvements are realized, and potential problems identified before being revealed by accidents or through external audits or inspections. The assessment program should be revised as necessary to be responsive to the needs of both the radiation-safety organization and senior management. Trending of assessment results should be used to feedback into the assessment program when planning for the next assessment cycle. If one program element is performing at a high level, assessment activities in that area may be reduced during the next selfassessment cycle. If trending indicates an area of concern is emerging, then more assessment activities should be focused and planned for that program element.

6. Qualification and Selection of Assessors The quality of a self-assessment program will depend in large part on the qualifications of the assessors. In this Report, qualifications refer to formal academic and other training, certification in a radiation-safety-related discipline, knowledge of the activities being assessed, and relevant experience. The qualifications that an assessor should have are related to the type of self assessment they are performing. As described in Section 3.4, self assessments can be performed at the program, process or task level. Assessors who are qualified to evaluate the overall radiation-safety program may not have sufficient qualifications to assess performance of specific radiation-safety tasks at the facility. Conversely, assessors who are adequately qualified to evaluate performance of specific tasks may not have sufficient knowledge or experience to assess the overall radiation-safety program. In general, individuals performing program- and process-level assessments should have a higher level of qualifications than individuals performing task-level assessments. Qualifications for assessing radiation-safety programs and processes are described in Section 6.1. Qualifications for assessing radiation-safety-related tasks are described in Section 6.2. 6.1 Assessors of Radiation-Safety Programs and Processes Individuals tasked with assessing radiation-safety programs and processes should have the following qualifications: • understanding of the self-assessment process including its purposes (Section 2.2), the types of self assessment (Section 3), assessment techniques (Section 7), and end products (Sections 11 and 12); • knowledge of and experience with the specific radiationsafety program area(s) they are asked to assess; • familiarity with the policies, procedures and instructions related to the facility’s radiation-safety program; 27

28 / 6. QUALIFICATION AND SELECTION OF ASSESSORS • knowledge of facility operations that require radiation-safety support and industry accepted good practices for implementing radiation safety within those areas of operation; • training and experience appropriate for the specific elements of the radiation-safety program being assessed; • independence from pressures within the facility that might bias their assessment results; and • knowledge of the applicable or relevant and appropriate regulatory requirements for the facility. Many of these qualifications are described in more detail in Sections 6.1.1 to 6.1.3. 6.1.1

Experience

It is desirable to have assessors with prior experience performing self assessments of radiation-safety programs or processes. However, this may not be achievable within a small institution. Individuals having experience with self assessments of functional areas other than radiation safety can be incorporated into the radiation-safety self-assessment team. Regardless of the assessors’ previous experience with self assessments of programs or processes other than radiation safety, the assessors should be trained in the requirements specific to the radiation-safety program or process at the subject facility. Although personnel experienced in performing self assessments may not be available when the self-assessment program is initiated, an experienced cadre of assessors can be developed over time. Finally, while assessments should largely be led by experienced personnel, the participation of individuals having lesser experience can bring new perspectives to the activity and may provide candidates for being assessors in the future. It is particularly valuable to have experienced assessors reviewing the qualitative aspects of a radiation-safety program (e.g., are funding, staffing, and staff qualifications adequate?). These qualitative aspects typically require more judgment than reviewing the more quantitative aspects of the program (e.g., are regulatory dose limits being met?). Two of the most important qualities of an assessor, which are often enhanced by experience, are having the ability to ask probing questions and identify systemic, program-level issues (while avoiding focusing on items of little value). 6.1.2

Knowledge of Area Being Assessed

Detailed knowledge by the assessors of specific day-to-day operations that require radiation-safety support and oversight at the

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facility is important. Personnel working within the radiationsafety program are generally the individuals most knowledgeable of each aspect of the radiation-safety program for their facility. However, there is a significant potential for these personnel to be biased in their assessment of the program. There is a fine line between assessors having comprehensive knowledge of the radiation-safety program at a facility and someone who is so vested in some aspect of the radiation-safety program that they cannot provide an impartial, objective assessment. Therefore, due to the inherent nature of the self-assessment process, it is particularly important for the assessor to be self critical. In general, it is not desirable to have radiation-safety staff members assess program areas for which they are directly responsible. In large radiation-safety programs, this is normally not an issue because adequate staff members are available. However, for smaller programs, the radiation-safety staff members may have to assess their own area of responsibility. In this situation, the assessor should make every effort to perform the self assessment in an objective manner. The self-assessment program should include management review of self-assessment reports to ensure that the reports are free from any apparent biases.

6.1.3

Training and Certification

Radiation-safety programs or processes can entail a broad spectrum of areas of specialization within the field of health physics and radiation protection. Personnel trained in one area of specialization may not be familiar with another radiation-safety program element. The highest level of qualification of an assessor may be professional certification in a related field (e.g., certification by the American Board of Health Physics, the American Board of Medical Physics, or the American Board of Radiology). However, there can be aspects of the facility’s radiation-safety program that are not within the areas of expertise of the certified professional considered as a potential assessor. For radiation-safety programs with a limited scope, using a certified professional is less important if the assessor is otherwise qualified. Also, it would be helpful for individuals performing risk-based assessments (Section 3.2) to have some training or experience in risk assessment. In general, all personnel selected to perform self assessments should, at a minimum, receive information or training in the following topics:

30 / 6. QUALIFICATION AND SELECTION OF ASSESSORS • institutional overview including the roles and responsibilities of the radiation-safety program or process within the institution; • description of operations supported by the radiation-safety program or process within the facility; • policies, procedures and instructions applicable to the radiation-safety program or process at the facility; • regulatory requirements (e.g., licenses, permits, regulations) applicable to radiation safety at the facility; • facility-specific self-assessment program, self-assessment program plan, and self-assessment performance criteria; and • guidance on how to conduct the self assessment, including interview techniques, making observations, and gathering and documenting findings. Training of assessors should be presented in a structured, documented manner that may include testing at the end of the training program to evaluate each assessor’s understanding of the selfassessment program. The training program should be described in detail in the self-assessment program plan and should be compatible with the overall training requirements of the facility. The training program should include clear and open discussions of the necessity for unbiased evaluations of each program element or process and the need to look closely at each program element or process being evaluated. Formal training may not be available or warranted at small institutions or facilities (e.g., a college handling small quantities of radioactive material or a diagnostic nuclear-medicine facility). In these situations, the individuals performing the self assessments would benefit from following the general principles and guidance for performing self assessments as presented in this Report. 6.2 Assessors of Specific Radiation-Safety Tasks Radiation-safety programs are implemented in a facility through performance of specific tasks by facility personnel. In many instances, nonprofessional personnel can perform these task-level assessments. The specific qualifications they should have are described in Sections 6.2.1 to 6.2.3. 6.2.1

Experience

As with program and process assessors, it is desirable to have task-specific assessors with prior experience performing self assessments. Personnel having little or no experience performing self

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assessments can be included in a self-assessment team to broaden the experience base of the organization. 6.2.2

Knowledge of Radiation-Safety-Related Tasks

There is a wide range of specific tasks associated with a radiation-safety program. Personnel who perform these tasks may be professional health physicists or health-physics technicians. Personnel who are experienced with a specific task may not be knowledgeable of the requirements of another safety-related task. Cross training of personnel at a facility is one way to develop employees who can participate more effectively in the self assessment of radiation-safety program tasks. 6.2.3

Training and Certification

Task-specific assessors should receive general training on the topics listed in Section 6.1.3. As for program assessors, the highest level of qualification of a task-specific assessor may be professional certification in a field related to radiation safety. However, many day-to-day tasks of radiation-safety programs can be performed by individuals who are registered as radiation-protection technologists or have similar areas of specialization. Also, in many instances, the individuals in the best position to assess radiation-safety-related tasks are the workers who carry out these tasks. Inclusion of these personnel in the assessment team can improve the overall team by exposing them to the overall program requirements (and associated program-administration responsibilities) while program professionals learn the details of each radiation-safety task. 6.3 Independence and Access to Management and Staff The independence of the assessors during the assessment should be made known to all affected personnel at the facility prior to the assessment. This independence is important in achieving unbiased evaluations of the radiation-safety program. During the assessment, assessors should have unrestricted access to all personnel who manage or perform radiation-safety functions, are subject to radiation-safety requirements, or are the recipients of the radiation-safety services related to the self assessment. Also, it is important for an assessor to be self critical, with an attitude of wanting to foster continuous improvement rather than just trying to make the program look good. It is far better for an institution to self-identify deficiencies rather than having them uncovered as the result of an accident or having them identified by an external auditor.

32 / 6. QUALIFICATION AND SELECTION OF ASSESSORS 6.4 Using In-House Personnel It is usually desirable and convenient to use personnel from within an institution to perform self assessments. First, in-house personnel will have some knowledge of the operations and the radiation-safety program being assessed. Second, it simplifies the process of site access and orientation and it normally costs less than bringing in personnel from the outside. Third, it is usually easier to accommodate any changes that have to be made in the self-assessment schedule if personnel from outside the institution are not involved. In-house self-assessment personnel can be from facility or line management, safety committees, radiation-safety program staff, authorized users, or radiation workers. Personnel should be selected based on their availability, knowledge and experience with the program elements being assessed, the associated hazards, and their knowledge of the radiation-safety program requirements. Management should ensure that personnel participating in the self assessment have sufficient time to perform their regular duties. Assessment personnel should be capable of collecting data through interviews, document reviews, and observations. It is very important that the personnel have effective interpersonal skills and be able to communicate effectively, both orally and in writing. The use of line and facility management or teaming with radiation-safety staff members on self assessments allows the line management to take more ownership of the performance of their organization in the radiation-safety program. When teaming with management, the radiation-safety staff would provide the subject matter expertise. Also, radiation-safety staff would be more suitable for performing assessments of the adequacy of specific functional elements of the radiation-safety program. For formal self assessments for large radiation-safety programs, the selection of in-house personnel should occur several months prior to the self assessment to provide sufficient time to prepare. A minimum lead-time of at least six weeks should be considered to allow for the appropriate level of planning and any necessary training. Self assessments of very small radiation-safety programs would normally require much less time. In-house self-assessment activities can be performed either by a team of individuals or by a single person. Comprehensive self assessments of programs and processes are generally performed by an assessment team with combined skills and experiences. The size of the team depends on the size and complexity of the radiation-safety program being assessed.

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When selecting in-house personnel to perform self assessments, attention should be given to the need for the assessor to maintain objectivity and to avoid conflicts of interest. For example, individuals should not assess areas for which they have direct responsibility. When deemed a potential issue, selecting personnel from other areas in the institution may be a viable option, particularly in larger institutions. In smaller institutions, using personnel from similar, sister institutions may be feasible especially if a reciprocity agreement for this purpose exists. 6.5 Self Assessments Supplemented with Outside Contractors or Independent Consultants Another option is using outside contractors or independent consultants to perform self assessments. Although this option costs more than using in-house personnel, it has the potential advantages of minimizing potential conflicts of interest and being more objective than self assessments done by in-house personnel. A potential negative aspect of using outside contractors is that the institution staff and management may not take ownership of the assessment process. Also, if the outside contractor identifies the need for follow-on work, consideration should be given to having the work done by another outside contractor or by in-house personnel to avoid a potential conflict of interest. Using outside contractors and independent consultants also has the potential benefit of having a fresh look at the radiation-safety program. Often these experts can bring in good ideas and practices from other institutions. If this option is used, these outside personnel should be qualified and experienced in performing assessments and have knowledge and experience regarding the part of the radiation-safety program to be assessed. Finally, a self-assessment team could be a combination of inhouse and outside personnel as a way to balance familiarity with organizational systems and an independent viewpoint.

7. Self-Assessment Methods and Techniques As discussed in Section 4.3, the radiation-safety program manager or the RSO typically has the responsibility for developing the self-assessment program. This responsibility includes selecting the methods to be used in performing specific self assessments (in consultation with the RSC as appropriate). There are numerous methods and techniques that can be used to evaluate the effectiveness of a radiation-safety program. These methods include reviews of the results of the radiation-monitoring program, workplace observations (both the workplace and worker activities), interviews, checklists, and document review. Each of these techniques is discussed in the following paragraphs. 7.1 Evaluation of the RadiationMonitoring Program Results The results of the radiation-monitoring program are important indicators for evaluating a radiation-safety program. These would include the results of the internal and external dosimetry program, area radiation surveys, area swipe surveys, air-sampling program, and the effluent monitoring program. Since the results of these measurements are primary indicators of the effectiveness of the radiation-safety program, the radiation-safety staff continuously evaluates them as they become available. However, a comprehensive review of the measurement results during a self assessment can provide an overview of the effectiveness of the radiation-safety program and could indicate aspects of the program needing attention. In addition to reviewing the radiation-monitoring program results, the evaluation should review the adequacy of the radiationmonitoring program, the training of the individuals performing the monitoring tasks, and the proper calibration and use of equipment used in making any measurements. The evaluation should also verify that any problems identified by the radiation-monitoring program were corrected in a timely manner and that action was taken to correct the problems and prevent their recurrence. The evaluation of this information should 34

7.2 WORKPLACE OBSERVATIONS

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help assess regulatory compliance, the use of appropriate radiationprotection practices, and the proper tracking and trending of radiation doses, levels, and contaminating incidents. 7.2 Workplace Observations Observations of work areas and of individuals (including members of the radiation-safety staff) performing tasks within the workplace are an important self-assessment technique. Observations of work areas should evaluate the adequacy of radiation-safety signs and labeling, radioactive-material storage, radiation shielding, workflow patterns, radioactive-material handling and containment equipment, and other workplace conditions (e.g., ventilation, lighting, and ambient noise) that could impact the safety of the work environment. Examples of observations in areas where patient x-ray procedures are performed would include the proper use of personnel monitoring equipment, the proper use of shielding, and the proper adjustment of techniques and collimation to match the size of the patient or body part being examined. Observations of individuals performing tasks in radioactivematerials handling areas should include the proper use of radiation detection and measuring equipment, the wearing of appropriate dosimetry devices, the adequacy of contamination surveys performed after handling radioactive materials and before leaving the work area, and the proper wearing of PPE, including respiratory protection. These observations should also evaluate the adequacy of radioactive-materials handling procedures, radioactive waste-disposal procedures, radiation-source security measures, controlled-area access procedures, and compliance with policies and procedures. Another effective self-assessment technique is to observe workers demonstrating how they perform tasks involving radiation sources. The demonstrations can involve the use of the actual radiation source or can be done while having the worker pretend (dry run) that the radiation source is present or in operation and to go through the procedures that are used with the radiation source. Such demonstrations can be an effective method of evaluating the use of proper protective clothing, radiation-measuring equipment, personnel monitoring, shielding devices, remote-handling tools, signage, waste disposal, area access control and source security when the actual work is not being performed. The individual making the observations must be well versed in all aspects of the requirements, the specific operations within the

36 / 7. SELF-ASSESSMENT METHODS AND TECHNIQUES work area, and the radiation-safety requirements for the procedures being performed. Observations of significant deviations from good radiationsafety practices within the work area should be corrected immediately and documented as a part of the self-assessment record. Observations of the radiation-safety staff during teaching and training can provide indications of how clearly, accurately and effectively information is being transmitted to individuals using radiation sources. Discussions with the trainees afterward can indicate the effectiveness of the teaching and training and indicate where changes might need to be made. Likewise, observations of the radiation-safety staff in performing routine-monitoring operations, radionuclide-handling procedures, radioactive-waste processing, or radiation emergency-response activities, can evaluate whether they are following the rules and procedures of the radiation-safety program. The taking of photographs can be helpful in documenting specific observations during a self assessment. Specifically they can be used to document deficiencies that need to be corrected and to show improvements after corrective actions have been taken. The policy regarding the use of photographs during a self assessment should be approved by both management and workers. The policy should also protect individual privacy and address the need to protect proprietary information. 7.3 Interviews of Personnel in the Work Area Interviews of individuals in the work area are an effective selfassessment technique. Good interview techniques should result in insights into the workers’ understanding of their responsibilities, knowledge and understanding of policies and procedures, completion of required tasks such as documentation of radiation measurements or radioactive-waste disposal, and commitment to implementing good radiation-safety practices. The number of interviews conducted should be sufficient to thoroughly evaluate the task, process or program being assessed. The manner in which questions are phrased (Michel et al., 2005) is important to an effective interview. Questions should not lead the worker to the correct answer and should be relatively openended. Therefore, a question asking workers to describe how they perform a certain task is preferable to asking them to confirm that they perform a task in a specific way (as described by the interviewer). The interviewer should present as little information as possible about the correct way for doing things until after the

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worker has described their method or understanding of the procedure. The interviewer should be careful not to interfere with the performance of the task being conducted during the interview process. While self-assessment activities can be used to educate the worker, their intent is to identify individuals in need of training or retraining or to point out opportunities for improvement in the training program or operating procedures. Interviews of workers should be designed to evaluate processes, procedures, training, etc., that are in need of attention or correction. They should not be adversarial or confrontational. The worker should be provided with the opportunity to express concerns, ask questions, or make suggestions for improving operating or safety procedures. An interview questionnaire is a predetermined list of questions that are designed to aid in choosing appropriate questions to ask and how best to pose each question. The questionnaire should cover all areas within the scope of the self assessment and provide sufficient space for recording comments on various aspects of the self assessment such as the adequacy of observed procedures and deficiencies in the worker’s replies to specific questions. The questions should be logical, smooth flowing, and cover all potential areas of concern. Each questionnaire should be designed specifically for the facility being evaluated, the specific program, process or task being performed, or the regulatory or policy requirements being evaluated. Examples of specific questions that could be asked of personnel in the work area include: • Would you describe the method that you use to survey your work area for contamination after you use radioactive materials? • What are the requirements and procedures for surveying radiation-producing equipment in the work area? • Would you describe the radiation-safety training that you have received? • What are the requirements for wearing radiation dosimeters in your work area? • Where can you obtain a copy of your radiation-exposure history? • If someone in this laboratory becomes pregnant, who can she contact to obtain answers to any questions regarding continued work in the laboratory during the pregnancy? • Would you describe the procedure you would use if you found radioactive contamination on your skin?

38 / 7. SELF-ASSESSMENT METHODS AND TECHNIQUES • If someone in your work area received an injury that might be contaminated, what procedure should be followed? • Would you describe the steps taken to ensure compliance with the radioactive-material security requirements? • Would you describe the different types of radioactive waste generated in this laboratory and the method used for disposing of each? • Do you have any suggestions for improving the radiation-safety program in your work area? • Describe how you use x-ray procedure technique charts for medical exposures? • What devices are available for you to use so you don’t have to hold patients during medical x-ray procedures? • How do you know that the radiation beam has successfully turned off following a medical procedure? • If you suspect that your x-ray machine is not operating properly, who do you call? • Would you describe how the interlock system for your radiation-generating device works? General guidelines and considerations for performing interviews during the self assessment of tasks are provided in Appendix A. 7.4 Use of Checklists One common self-assessment tool is a checklist. The self-assessment checklist should at a minimum address basic safety concerns, as well as the legal, regulatory, and licensing requirements under which the institution operates. In addition, it should address the institution’s internal procedures, general good housekeeping, and any worker concerns. Self-assessment checklists and other tools should be specific to the institution performing the self assessment. Radiation-safety program personnel may also want to review or utilize self-assessment checklists and tools used by other institutions, some of which can be found on the Internet. There are examples of checklists from a wide range of institutions including research, academic, medical, dental and industrial, which can be an excellent starting point for developing or reviewing a site-specific self-assessment checklist. When developing a checklist, radiation-safety program personnel should get input from those outside the radiation-safety program regarding clarity and relevance of questions asked or information requested. It may be necessary to get management approval for these checklists. When completed, the checklist should

7.4 USE OF CHECKLISTS

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provide a tool to help determine if all aspects of the task, process or program being assessed are understood and practiced on a routine basis and in a manner that is consistent with good radiation-safety practice. While checklists are useful adjuncts for doing self assessments, they should not dominate the process. A desire to complete a checklist as quickly as possible is not conducive to a good self assessment. A completed checklist is not the goal of a self assessment; rather, the goal should be the detection of problems, weaknesses and deficiencies in the radiation-safety program. Individuals performing the self assessment must be sufficiently knowledgeable to recognize not only deviations from the items of concern that are listed on the checklist but they should also be able to recognize deficiencies not addressed by the checklist. Specific questions that could be included in a checklist are provided by regulatory agencies. For example, Fuller et al. (1999) contains an extensive list of questions assessing a radiation-safety program: • Are all users and laboratory locations listed in the license? • Are all users properly trained and do they have adequate experience? • Are training programs required and records maintained? • Are users cognizant of proper safety and emergency procedures? • Are users cognizant of dose limits and their own doses? • Are all materials used, quantities, and forms listed on the license? • Are leak tests performed as required on the license? • Is an inventory of radioactive materials kept up-to-date? • Are radiological-survey instruments calibrated as required? • Are laboratories adequately surveyed after use of radioactivity? • Are records properly maintained? • Are workers trained to open packages properly? • Are workers properly monitored? • Are rooms properly posted? The above questions are directed primarily at users of radioactive material. Although many of these questions would be appropriate for operators and users of accelerators, the questions should consider the need to address specific facility policies and procedures. For example, Safety of Accelerator Facilities (DOE, 2004) lists the specific requirements for accelerator facilities in the DOE complex.

40 / 7. SELF-ASSESSMENT METHODS AND TECHNIQUES Some additional questions that could be asked in a self assessment of a DOE accelerator facility are: • Is the safety assessment document complete and up-todate? • Are there any unreviewed safety questions? • Are written procedures complete and up-to-date? • Is an internal review system established and maintained? • Is there a written shielding policy for ionizing radiation? Has this policy been implemented? 7.5 Document Review Reviewing radiation-safety program documents is a valuable technique in conducting a self assessment. In addition to the radiation-monitoring results discussed in Section 7.1.1, these documents would include reports of unplanned radiation exposures and contamination incidents, including frequency, severity potential, and corrective actions. These documents would also include training and post-training tests, quality-control test results (e.g., personnel dosimetry, sample counting laboratory, and instrument calibration), regulatory agency inspection results, performance measure results, and a summary of radiation-safety problems within specific work groups or within the overall radiation-safety program. Written policies and procedures should be reviewed periodically to ensure that they are current and that they correctly describe the tasks, processes or programs to which they apply. 7.6 Documentation of Results Whichever methods and techniques are used in a self assessment, they should be properly documented. Also, regardless of which methods and techniques are used, it would be helpful for the results to be available in digital format to facilitate review, distribution, and record keeping (see Section 11 for more information on documenting self assessments).

8. Types of Deficiencies, Response Priorities, and Noteworthy Practices As discussed in Section 2, one of the most important purposes of a self assessment is to identify deficiencies in the radiation-safety program so they are responded to in an appropriate manner. A deficiency may have consequences that range from a minor administrative infraction to a severe safety hazard, with categorization based on its potential risk to workers, the public, or the environment. However, the vast majority of deficiencies identified during a self assessment are likely to be relatively minor, with serious deficiencies likely to be associated with major incidents or accidents. The level of the deficiency determines the response priority, which is based upon the following: • level of potential risk to workers, the general public, the environment, the magnitude of other institutional risks, and the probability of occurrence; and • reporting requirements promulgated by relevant regulatory authorities. For example, several agencies such as NRC (Agreement States), DOE, OSHA, and EPA require immediate notification if an item of noncompliance presents an imminent threat of death or serious physical harm. Other notification requirements are specified for events of lesser consequence. Minor deficiencies typically require routine reporting or they may not require any notification at all outside of the institution. Section 8.1 contains examples of deficiencies that would likely require only routine (or no) reporting to regulatory agencies, Sections 8.2 through 8.4 contain examples that would require timely (i.e., associated with a moderate risk), prompt (i.e., associated with a serious risk), or immediate (i.e., associated with a severe risk) action be taken. The examples are only intended to provide general guidance and it is possible that the specific circumstances of the deficiency would warrant a higher response priority. 41

42 / 8. TYPES OF DEFICIENCIES It is equally important for self assessments to identify noteworthy practices that may be applied to other programmatic areas in order to facilitate continuous improvement at an institution. Therefore, self assessments should also be designed to identify exemplary performance by individual workers or groups of workers. Section 8.5 contains examples of noteworthy practices. 8.1 Identified Deficiencies that Require Routine Response A minor (or negligible, depending on the circumstances) hazard is one that has limited adverse impact on the radiation-safety program. These types of deficiencies are the most likely to be identified in a self assessment of a radiation-safety program. The following deficiency examples could trigger a routine response and mitigation action. • incomplete radiation survey records; • failure of safety system that has a redundant and functional backup component without replacement ordered; • working in a well-characterized radiation area without adequate dosimetry but where the dose potential has historically been low; • radiation survey equipment exceeds recalibration interval by small amount (e.g., less than one month); • use of a respirator by a worker that does not fully comply with an approved respiratory protection program (e.g., respirator not properly maintained, poor fit of respirator to wearer, untrained or improperly trained respirator user) per ANSI/AIHA (2006) or NRC (2002); • protective clothing (e.g., gloves, laboratory coats, shoe covers, pants, etc.) not worn when working with unsealed radioactive material or where their use has been specified, but the hazard is minor; • removable radioactive contamination in unposted areas that is slightly in excess of the applicable release criteria; and • minor deviations from established work procedures that are not likely to result in a demonstrable safety impact. Deficiencies that could result in this level of hazard should be followed as part of the self-assessment process, with the root cause, follow-up actions, employee retraining, and closure status documented in a corrective-action plan (Section 12).

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8.2 Identified Deficiencies that Require Timely Response A moderate hazard is one that has the potential to cause a radiation exposure in excess of regulatory dose limits, property damage, regulatory fines or penalties, or adverse public response. Mitigating actions should be initiated within a week or less (depending on the specific circumstances) for radiation-safety program deficiencies such as the following: • engineered safety systems not functioning but with management/administrative controls still in place (e.g., ventilation system at a research reactor not operating to keep room at negative pressure, but reactor system shutdown or radiation detectors not functioning, but sources remain shielded/ contained); • engineered safety system functioning but out of compliance with test schedule (e.g., interlocks to high radiation area not tested within the specified interval); • failure to leak test sealed radiation sources within prescribed time frames; • storage or use of food within a radiologically restricted area; • failure to properly secure radioactive material in concentrations or amounts that exceed regulatory exempt quantities; • potential for property damage, but limited to the immediate work area; and • failure to properly conduct radiation surveys. A deficiency that could result in this level of hazard also requires timely action that may include, but is not limited to, notification of management such that appropriate and timely corrections may be implemented. In addition, the root cause, follow-up actions, and closure status should be documented in a correctiveaction plan (Section 12). 8.3 Identified Deficiencies that Require Prompt Response A serious hazard is one that could result in injury or occupational illness, environmental harm, or property damage. This level of deficiency is unlikely to be encountered during a self assessment of a radiation-safety program. However, examples are given primarily to provide perspective on the full range of deficiency types. Prompt action to control, contain and mitigate the hazard is indicated if radiation-safety program deficiencies are identified:

44 / 8. TYPES OF DEFICIENCIES • unguarded or unsecured access to: - areas with significantly elevated ambient dose rates [i.e., in excess of 50 mSv h–1 (5 rem h–1)] or - areas with significantly elevated airborne radioactivity concentrations (i.e., in excess of 2,000 times the applicable derived air concentration); • falsification of a radiation-safety record that could lead to or mask the presence of a serious radiation hazard; • theft or loss of control of radioactive material in excess of 100 times the quantities listed by NRC (2007) or 50 times the quantities listed DOE (2008a); • uncontrolled access to special nuclear materials in quantities that are greater than five times the lowest annual limit on intake specified by NRC (2008a) or DOE (2008a); • nonfunctional radiation survey meters, monitoring systems, or alarm systems; and • potential for property damage, but limited to the facility. A serious hazard requires prompt action by the individual conducting the assessment to ensure the deficiency is eliminated or mitigated. Mitigating actions should be initiated within a day or less depending on the circumstances. Such action may include, but is not limited to, notification of management and relevant regulatory authorities. In addition, the root cause, follow-up actions, employee retraining, and closure status should be documented in a corrective-action plan (Section 12). 8.4 Deficiencies that Require Immediate Response A severe hazard is one that has the potential to cause death, severe injury, or occupational illness, significant risk to the public, extensive environmental harm, or significant property damage. It is highly unlikely that a deficiency resulting in a severe and imminent hazard would be identified during a self assessment. Nonetheless, the following examples are provided: 1.

unguarded or unsecured access to: - areas with significantly elevated ambient dose rates [i.e., in excess of 250 mSv h–1 (25 rem h–1)], - areas with significantly elevated airborne radioactivity concentrations (i.e., in excess of 10,000 times the applicable derived air concentration), or - radiation sources or radiation-producing machines that meet the definition of IAEA Category 1 or 2 (IAEA, 2005);

8.5 NOTEWORTHY PRACTICES

2.

3.

4.

5. 6.

7.

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work practices that may result in uncontrolled release of radioactive materials in quantities or concentrations sufficient to endanger the life or health of workers or the public or significantly harm the environment; work being performed in areas with significantly elevated exposure rates without the use of functioning radiationmonitoring devices and/or alarming personal dosimetry; work being performed in areas that contain fissile materials in concentrations or amounts capable of producing a chain reaction but without adequate criticality controls in place; intentionally-bypassed interlock such that an Item 1 (above) deficiency is possible; presence of nonradiological hazards (e.g., fire, electrical, chemical) that pose imminent risk of physical harm to personnel; and potential for property damage that could extend outside the facility and possibly offsite.

If a severe deficiency is identified, immediate action must be taken. Such action may include, but is not limited to, calling for an immediate stopping of work at the work site (with specific work activities permitted to proceed to a safe condition after issuance of the stop-work order), immediate notification of management and relevant regulatory authorities, and lockout/lockdown of applicable equipment and facilities. In addition, the root cause, follow-up actions, and closure status should be documented in a corrective-action plan (Section 12). 8.5 Noteworthy Practices In addition to identifying deficiencies in a radiation-safety program, it is important that self assessments identify noteworthy practices that can be implemented in other programmatic areas as part of a continuous improvement program. Also, self assessments should identify exemplary performance so that individual worker contributions are acknowledged. The following are examples of noteworthy practices that may offer improvements in performance and dose reduction: • worker-proposed and ALARA-based procedural revisions that lead to a cost-effective reduction in occupational radiation doses; • setting of high standards for following established radiation-safety procedures by radiation-safety personnel;

46 / 8. TYPES OF DEFICIENCIES • improved inventory and accountability systems that enhance the level of sealed-source security; • recommendations for cost-effective modifications to equipment and materials that improve contamination control, decrease the likelihood of uncontrolled releases of radioactive material, or otherwise offer dose reduction; • development or implementation of the use of software to automate radiological data calculations and records storage with improved accuracy and efficiency; and • development of waste minimization strategy that avoids the generation of mixed waste that is costly to treat or dispose of. Noteworthy practices should be shared with other radiationsafety program areas where they might be applicable.

9. Planning an Individual Self Assessment As discussed in Section 5, an individual self assessment is generally performed within the framework of an overall selfassessment program. The program framework will establish the assessment topic, type of assessment, the frequency and time frame for performing the individual self assessments, and the general qualifications of assessors. The challenge of the self-assessment program is to assess performance with minimal intrusion to the institution, which also increases the likelihood that workers will perform ongoing tasks, processes and programs as if they were not being observed. Intrusion on ongoing activities can be minimized if the frequency and planning of individual self assessments are optimized. In preparation for an individual self assessment, management should plan how to conduct the assessment. The level of planning will vary significantly depending on the scope, breadth and complexity of the task, process or program being assessed. Management should establish the guidelines for: • scheduling the assessment and allocating time for planning, conducting and documenting the assessment; • the focus of the self assessment; • the assessment techniques to be used; • the specific numbers and qualifications of personnel assigned; • the responsibilities of assessment personnel; • any proprietary or security limitations such as restricted use of cameras or restricted access due to security; • recordkeeping; and • tracking and follow-up on any deficiencies identified by the self assessment. These factors should be documented in the individual selfassessment plan and approved as specified in the self-assessment program plan to ensure that the appropriate level of management or the RSC concurs with the plan. A well-developed and written individual self-assessment plan will greatly improve the quality 47

48 / 9. PLANNING AN INDIVIDUAL SELF ASSESSMENT and focus of the assessment and will align the assessment with the institution’s needs and priorities. 9.1 Schedule for an Individual Self Assessment The schedule for performing an individual self assessment identifies the appropriate allocation of time for planning, conducting and documenting the self assessment. The schedule will depend on the breadth and complexity of the radiation-safety task, process, program element, or program being assessed as well as the resources the organization can allocate to the assessment. The schedule for conducting a self assessment should provide adequate time to develop the individual self-assessment plan, obtain the appropriate resources, perform the necessary document reviews, perform the necessary field observations and interviews, and document the findings and observations, both strengths and weaknesses. Corrective actions are tracked but are not part of the self-assessment schedule itself. The schedule should be included in the self-assessment plan. When scheduling a self assessment, consideration should be given to audits or inspections that are scheduled to be conducted by a regulatory agency. For example, it might be useful to schedule a self assessment of a program element prior to an inspection by a regulatory agency. 9.2 Task Assessments The job observation is the least formal of the self-assessment types and is often used to do a task assessment. It may consist solely of a checklist based on the task expectations or the procedure for performing the task rather than a formal self-assessment plan. The time spent planning for this assessment is minimal since the procedure or task expectations already exist and can be readily reviewed. The institution’s self-assessment program may address planning for and conducting job observations, thus eliminating the need for an individual task or job observation self-assessment plan. In these types of assessments, the majority of time is spent in conducting field observations. The schedule is therefore limited in scope and formality. Documentation of a single task assessment should be completed within a day or two of the field observation. 9.3 Process, Program Element, and Comprehensive Program Assessments The formality of process, program element, and comprehensive program assessments requires that the schedule provide adequate time to develop the self-assessment plan, obtain the appropriate

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resources, perform the necessary document reviews, perform the necessary field observations and interviews, and document the findings. As the scope of the assessment increases, so should the formality of the assessment process and the time allocated to prepare for it. With increasing formality, the time allocated to planning for the assessment should also increase. Proper planning helps to minimize the impact of the assessment on the rest of the institution. As an example, the schedule for a self assessment of program elements at a nuclear power plant or other nuclear fuel-cycle facility could stretch over several months. Typically, several weeks would be allocated to develop the self-assessment plan, obtain the appropriate resources, and perform the necessary document reviews. Once the self assessment begins, field observations and interviews can take two to four weeks, and writing the report can take an additional two to four weeks. On the other hand, the self assessment of a physics laboratory using a few small radiation sources could probably be completed in a day or two. 9.3.1

Selecting the Focus of the Assessment

As discussed in Section 5, individual self assessments of tasks, processes, program elements, or a comprehensive program are performed within the framework of an overall self-assessment program plan. Once the task, process, program element, or comprehensive program has been selected for assessment, the assessor or assessment team must develop the individual self-assessment plan. With the exception of task-level self assessments, which are well defined, the self assessment of processes, program elements, or the comprehensive program, may require the team leader or assessment team to focus the assessment. For example, it may not be feasible or necessary to assess all tasks within a process, all processes within a program element, or all program elements within the comprehensive program with the same level of scrutiny to meet the objectives of the individual self assessment. Initially, the focus areas should be based on their importance to radiation safety, the frequency at which they are performed, deficiencies found during prior self assessments, and the expectations of management. During the assessment, the level of scrutiny can be modified to focus on areas where problems are identified. 9.3.2

Assessment Tools

Assessment tools are described in Section 7 and should be identified and documented in the plan for any individual self assessment. As the assessment progresses, other assessment tools may be added based on the information that is being obtained.

50 / 9. PLANNING AN INDIVIDUAL SELF ASSESSMENT 9.4 Responsibilities of Assessment Personnel The qualification and selection of individuals performing self assessments are discussed in Section 6. This section discusses the responsibilities of the individuals who will be conducting the self assessment. Once a decision is made to perform an individual self assessment, and depending on the scope of the assessment, either a single assessor or self-assessment team leader should be appointed. A single assessor is generally sufficient when performing an individual assessment of a small radiological program (e.g., a small research laboratory or a small industrial user of radioactive material). If the scope of the assessment is sufficiently complex that it warrants a team, then the duties are commonly assigned as follows. 9.4.1

Team Leader

The responsibilities of the assessor or team leader include: • communicating with the manager/supervisor requesting the individual self assessment to determine the scope, objectives and schedule for the requested self assessment; • assembling the assessment team that provides the requisite technical expertise and is of the appropriate size to complete the assessment in the allotted time; • reviewing findings and corrective actions of previous audits and self assessments; • developing the self-assessment plan including performance objectives and criteria, checklists, guides, interview sheets, schedules and agendas, and obtaining the essential site documentation; • coordinating logistical and administrative activities; • leading the self-assessment meetings including the scoping meeting with the requesting manager, any team meetings prior to the assessment, the entrance and exit meetings, and any briefings during the assessment; • adjusting priorities and delegating activities to team members during the assessment; • developing a consensus on the findings and observations and working to resolve conflicting opinions (infrequently a minority opinion which cannot be resolved should be reported as a minority opinion); • developing the overall recommendations to address any identified deficiencies;

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• providing the opportunity to do a factual accuracy check of the draft report to those individuals responsible for the activities that have been assessed; and • preparing and issuing the self-assessment report and managing the supporting information. 9.4.2

Team Member

Team members are responsible for: • completing personal preparation such as a review of pertinent regulations, license or contract requirements, implementing policies and procedures, relevant performance measures, results of previous audits and/or assessments affecting the radiation-safety program to be reviewed, any regulatory violations, and any accidents or injuries that have occurred; • conducting the assessment tasks as assigned and documenting observations and interviews; • developing conclusions and recommendations for input into the final report; and • supporting the team leader, if requested, in presenting the conclusions and recommendations at the exit meeting, if one is held. 9.5 Criteria for Assessment As discussed in Section 2.1, self-assessment criteria are primarily derived from regulations, standards, internal policy documents, implementing procedures, industry best practices, and institutional goals. Review of these program documents can help team members determine what personnel interviews will be necessary and what activity observations should be made. This documentation could include: • • • • • • • • • • •

federal and state regulatory requirements; license conditions and/or contract requirements; appropriate codes and standards; regulatory guidance; policies; procedures; directives; organization charts; modification or change packages; facility drawings; vendor manuals;

52 / 9. PLANNING AN INDIVIDUAL SELF ASSESSMENT • • • • • • •

logbooks; shift turnover sheets; performance measures; audit reports; regulator reports and/or items of noncompliance; previous self-assessment reports; internal problem identification and corrective-action documentation; • management reports; • external assessment/review reports; and • quality assurance manuals and quality-control charts.

Self-assessment criteria can also be based on reviewing the history of past incidents (e.g., radiation over exposures, contamination incidents, misplaced radioactive material, and near misses). The intent of selecting these criteria is to minimize the likelihood of the recurrence of specific types of incidents. 9.6 Preassessment Coordination In the conduct of any self assessment, coordination of the specific details with the organization to be assessed is essential to ensure that the purpose of the self assessment is clear, the assessment can be accomplished in the time allotted, and the appropriate personnel will be available to answer questions. This coordination will aid in conducting a self assessment with maximum effectiveness and efficiency with minimal intrusion to the ongoing tasks, processes and programs of the institution. In addition, any necessary arrangements for personnel not normally assigned to the facility or institution will need to be identified and may include security authorization [e.g., security clearance, determination of trustworthiness and reliability (Appendix B.6)] or escort, general institution or facility-specific training, dosimetry and bioassay requirements. Coordination with the organization to be assessed may be accomplished by a planning meeting held several weeks prior to the entrance meeting. Once the self-assessment planning and logistical arrangements are completed, a schedule for the conduct of the self assessment should be finalized. The schedule should include a start and end date for the self assessment. It could also include tentative dates for the completion of document reviews and data collection, issuance of the draft report and factual accuracy review, and final issuance of the report. The scheduling of self assessments of a small scope would be correspondingly less complex.

10. Conducting the Self Assessment The degree of formality of a self assessment will depend on the breadth and complexity of the radiation-safety program being assessed. The format outlined in this section would be appropriate for a formal self assessment of an extensive and complex radiationsafety program such as at a large university, a large industrial user of radiation sources, a large government research laboratory, or a nuclear power plant. For smaller, less complex radiation-safety programs such as at a small college, the degree of formality can be scaled accordingly. 10.1 Entrance Meeting The primary purpose of the entrance meeting is to introduce the assessment team to the facility management, supervisors, and key employees. It is appropriate for each self-assessment team member to be introduced to his or her point of contact in the task, process or program area being assessed. A copy of the self-assessment plan should be distributed to and reviewed with self-assessment participants. This review provides an opportunity for self-assessment participants to ask questions and provide any comments or feedback. An example of a self-assessment briefing agenda is provided in Figure 10.1. 10.2 Assessment Activities As discussed in Section 7, assessment activities typically consist of a combination of document reviews, interviews, and field observations. The relative proportion of time spent on each of these activities depends on the nature and objectives of the assessment plan. To adequately assess performance, emphasis should be placed on observing actual work tasks and processes. Observing and interviewing radiation workers to determine the scope and depth of their knowledge of radiation-safety procedures are very useful self-assessment techniques. It is important to ask open-ended questions to encourage personnel to demonstrate or discuss their understanding of the task, process or program. 53

54 / 10. CONDUCTING THE SELF ASSESSMENT

Example Self-Assessment Agenda • team members, their qualifications, organization and interfaces • assessment scope and performance criteria • dates of the assessment • schedule of assessment meetings - preassessment - daily - post-assessment • list of documents needed for the assessment • logistical support such as office space, phone access, and administrative support • safety briefing • points of contact for each functional element Fig. 10.1. Example of self-assessment briefing agenda.

Assessors should pay particular attention to any near misses that have occurred. Near misses are incidents that have occurred with minimal consequences, but have the potential for significant consequences if the incident recurs. Near misses, including unanticipated radiation doses, should be investigated to help prevent recurrence of potentially more significant incidents. It is important for maintaining open communications that any deficiencies reported by interviewees be credited to the interviewee rather than the assessors taking credit for having identified them. 10.3 Daily Team Conferences If a team is performing the assessment, the team leader should conduct a team meeting each day of the assessment to provide each team member an opportunity to:

10.6 DOCUMENTATION

• • • • •

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update assessment progress; identify upcoming activities; evaluate outlook for completing assessment objectives; provide input of interest in other team member’s areas; and identify any deficiencies that were determined to be an imminent and serious threat to employee health and safety and immediately brought to management’s attention (as discussed in Section 8.4). 10.4 Management Briefings

The assessor or team leader should brief management frequently on the findings (both positive and negative), issues identified to date, the status of the assessment, and the outlook for completing the assessment as planned. Upper management should be notified as soon as possible if findings require immediate attention (see Section 8 for a discussion of the types of deficiencies that require immediate attention). 10.5 Exit Meeting The exit meeting should be scheduled at the entrance meeting or at one of the upper management briefings. The assessor or team leader should present the significant assessment issues, and, if a team assessment, each team member should present the conclusions and recommendations for the area assessed. The team leader directs the exit meeting and may make a summary presentation, but the team members should present the conclusions. There should be no completely unexpected findings presented at the exit meeting, as they should have already been communicated during management briefings. 10.6 Documentation Information gathered during the self assessment should be retained at least until the final self-assessment report (Section 11) is completed and issued. This supporting information includes: • interview summaries including the objectives of the interviews, a list of personnel interviewed, and their positions; • documented field observations that focus on the symptomatic results rather than the individual performing the task or tasks (the significance of written items should be obvious or they should include a statement of the significance);

56 / 10. CONDUCTING THE SELF ASSESSMENT • list of documents reviewed, with specific citations associated with any issues found; • completed checklists or questionnaires used in the assessment; • completed criteria worksheets, including any issues, noteworthy practices, conclusions, and whether criteria were met; • administrative records such as request for an assessment, selection of the assessment leader and team members, transmittal of the report, and letters of appreciation to assessment team members; and • documented corrective actions taken during the assessment. It is essential to document results, including completion of checklists or other tools used, in a timely manner. Ideally, the assessor will document results daily, keeping up with the pace of the assessment. This is important to ensure accuracy of the results. It also facilitates management briefings and timely report writing.

11. Documenting the Self Assessment 11.1 Written Reports Self-assessment activities provide the most value when the results are communicated clearly to the proper audience so that the appropriate response can be initiated. Written reports are often used as the vehicle to report findings to the groups assessed and to other interested parties such as management, regulators, and quality-assurance organizations. The written report should include descriptions of the scope and objectives, the methodology used, results, conclusions, and recommendations. When completed, the self-assessment report should be an impartial statement of the current health of the task, process or program assessed. It should include detailed assessment results, and discussion of associated significance or severity of issues identified (using the conventions established in Section 8). It serves as a complete record of the planning, conduct and outcome of the assessment, and provides appropriate details for entry into a deficiency or corrective-action tracking system (Section 12). The detail and formality of the self-assessment result will depend on the type and extent of the self assessment and on management expectations. Often the format will be driven by the standards of the institution being assessed; this section describes basic information that should be included. An example report format might include the following sections. 11.1.1

Title

An assessment report should be titled with the activity and organization assessed and periodicity, if applicable, along with the report issue date. 11.1.2

Summary

State the nature and the outcome of the assessment, including what was assessed, who performed the assessment, when it took place, and how the assessment was conducted. Summarize the assessment results, including a roll-up of the issues, opportunities 57

58 / 11. DOCUMENTING THE SELF ASSESSMENT for improvement, and noteworthy practices found. Provide an overall conclusion regarding the health of the task, process or program element that was assessed. 11.1.3

Scope

A self-assessment report should include a scope statement that identifies the breadth and depth of the tasks, processes and/or programs that were evaluated. The scope should include the type of assessment conducted; performance, risk or compliance based or combination thereof. 11.1.4

Methodology and Techniques

The methodology and techniques used should be described in some detail. This would include interviews conducted, checklists used, documents reviewed, performance measures evaluated, and observations performed. Report details may also include the number of individuals interviewed, descriptions of activities, processes or program elements reviewed, and facilities evaluated. The report should also include any photographs taken (using the guidelines discussed in Section 7.1.3). The assessment team should be described; names, organizations and positions of the assessors should be included. If any outside personnel were used as consultants or experts, they should be identified along with their affiliations and involvement with the assessment. 11.1.5

Results

The most important products of a written report are the assessment results and recommendations. Since a primary purpose of a self assessment is to identify and correct deficiencies, the results of the assessment will lead to corrective actions taken or assigned. The results of a self assessment should provide an overview of reviewed tasks, processes or programs, program strengths and weaknesses, and identification of any causes for deficient performance with recommendations for improvement. Deficiencies found during the assessment must be documented explicitly and in enough detail to enable causal analysis and resolution (Section 12). Issues may be ordered by subject area, but should include an indication of severity. Institutional standards may drive the use of specific terms such as findings, deficiencies, observations, concerns, or opportunities for improvement; the assessor should apply these as required, within the context of severity

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and urgency described in Section 8. Supporting, objective information is helpful in understanding the basis and extent of the identified issue. This information may include the number of instances and locations where a deficiency was observed, the specific details behind an identified noncompliance, or the advantages and potential applications of a noteworthy practice. More detail provides better communication and enables more effective resolution of the identified issue. For completeness, any deficiencies that are resolved or corrective actions underway during the self assessment should be described in the self-assessment report. When evaluating the overall performance of a series of tasks, processes, or an overall radiation-safety program, the results should be balanced considering the significance of the issues identified. For example, if the areas assessed are generally being performed effectively and efficiently, an accumulation of very minor deficiencies should not be used to portray the program as having major problems. Conversely, major deficiencies should not be discounted because much of the program is functioning well. Comparison with standards is important to ensure that the assessment is objective and consistent from assessment to assessment. Any issue identified as noncompliant with a standard should be discussed in detail along with the specific citation in the standard. The report should also include a discussion of the basis of the standards that are used, whether they are based on regulatory requirements, program requirements, industry standards, or management expectations. If previous corrective-action plans have been reviewed as part of the assessment, discuss overall effectiveness of previous corrective actions. If prompt corrective actions were taken during the assessment, they should be documented with the associated issue. Performance measures may be used by the radiation-safety program to monitor performance, identify improving or declining trends, and identify emerging issues. In addition, performance measures can also identify the quality, timeliness and effectiveness of corrective actions. If performance measures were used or evaluated during the self assessment, the associated analysis should be included in the results section. The analysis should include a discussion and, if appropriate, graphical or tabular representation of performance trends. The report should assess standards and performance measures for their ability to ensure continuous improvement by addressing whether or not associated goals were challenging. The report should also include discussion of changes to improve self-assessment activities such as:

60 / 11. DOCUMENTING THE SELF ASSESSMENT • adjustments in goals or changes to the measured areas when excellent performance is achieved; and • development of new performance measures or assessments when performance is not improving; or • development, implementation or adjustments to the performance measure system to monitor program performance. Finally, the report should document noteworthy practices that were identified during the self-assessment process. The specific practices should be described in enough detail that they could be implemented in other areas as appropriate. 11.1.6

Approval

The self-assessment report will have value only if management accepts the report and conclusions. Therefore, the appropriate division or department manager should approve each self-assessment report. The individuals whose program areas are being assessed should have the opportunity to do a factual accuracy check of the findings before the report is finalized to ensure that the facts on which the conclusions will be based are correct. It is not appropriate for the factual accuracy check to influence the conclusions that are drawn by the assessors unless the bases for conclusions are found to be in error. Self-assessment reports should not be edited to de-emphasize negative findings within the institution conducting the self assessment. In larger institutions, review and concurrence could be sought from a quality-assurance organization. Approvals by the assessors on the team, the team leader, and management should be documented in cover material. 11.1.7

Attachments

Because the self-assessment report serves as a permanent record of the assessment activities, it is important to include complete supporting documentation. Attachments typically include:

• • • •

copy of the assessment plan; completed checklists or other documented criteria tools; list of documents reviewed; documentation of resolution to past weaknesses, examples of program strengths; • list of personnel interviewed; and • qualifications of team members.

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11.2 Communication of Results to Affected Personnel The distribution of the report and results is determined by management. Commonly the self-assessment report is distributed to all related line managers, upper management, and to appropriate radiation-safety staff and RSC if applicable. Some institutions may have a performance assessment group and/or quality-assurance organization that should receive copies of the self-assessment report. Reports may be distributed via hardcopy and/or electronically, at the discretion of management. Hardcopy reports should include all attachments, while management may consider a less formal format for electronic distribution to stakeholders. It may be helpful to verbally communicate the pertinent portions of the self-assessment report to work groups or individual workers. This can promote discussion of how best to correct the deficiency and it also demonstrates management commitment to the self-assessment process. 11.3 Reports to Regulators The self-assessment program results are a valuable resource to demonstrate to regulators that assessments are being conducted, performance improvement is tracked and trended, and that corrective actions are implemented and are effective. With this thought in mind, a good self-assessment program provides a valuable tool to both enhance performance as well as demonstrate to regulators that the risk of radiological activities is being adequately managed and that the institution is committed to safe use of radiation and radioactive material. While there may be concerns that providing self-assessment reports to regulators may be counterproductive, most regulatory schemes are designed such that self identification is preferable to identification by the regulator, and certainly aggressive self assessment and issue resolution is preferable to preventable radiological incidents. The requirement to share self-assessment reports with regulators is established by each regulator. Even when a regulator, such as EPA, does not require the sharing of self-assessment reports, they do require the disclosure of significant deficiencies found during a self assessment (EPA, 2000). 11.4 Note on Legal Considerations The process of self assessment generally looks for deficiencies and by its very nature results in a report that lists weaknesses, vulnerabilities, regulatory noncompliance, and programmatic or

62 / 11. DOCUMENTING THE SELF ASSESSMENT personnel failures. In this context, some consideration should be given to legal consequences such as the potential use of a critical self-assessment report in a legal proceeding. Therefore, a report should: • be factual (observations and comments should be compatible with industry standards of practice); • be complete (avoid requiring interpretation of the results); • protect sensitive information [confidential or proprietary material and information should be labeled appropriately and distribution limited avoid including personal information (e.g., use job titles rather than names)]; • avoid opinions and pejorative words such as negligent, unsafe and reckless; • make recommendations that are advisory rather than commanding (recommendations should allow for differing opinions and differing implementation methods); and • avoid drawing a legal conclusion, stating that a condition does not appear to comply with regulations would provide the opportunity for further discussion and possible clarification rather than stating a condition is a “violation of the law.” When generating a document, presume that the report could be used in legal proceedings and/or be available to the public. If the report was written factually with recommendations for deficiency correction and program improvement, then even if it becomes public, it should be viewed as objective and program-improvement oriented.

12. Documenting Deficiencies and Corrective Actions In an effective self assessment of any radiation-safety program, it is likely that some deficiencies will be identified. Corrective actions should be developed for each of the deficiencies in accordance with institutional, management and regulatory expectations. The deficiencies and their associated corrective actions should be documented. This section provides guidance on developing such documentation. 12.1 Deficiency and Corrective-Action Tracking System Deficiencies and corrective actions should be documented in a deficiency and corrective-action tracking system. For larger radiation-safety programs, this tracking process is often in a computerized format. This facilitates updating the tracking system and distributing the report to appropriate personnel. The deficiency and corrective-action tracking system should be reviewed periodically by management to ensure that deficiencies are resolved in a timely manner. After initial approval, modifications to corrective actions or associated due dates should be approved by management. 12.1.1

Categorization of Deficiencies

Identified deficiencies need to be categorized based on their potential impact on the radiation-safety program. The level of deficiency can range from an opportunity for improvement, to a minor noncompliance issue, up to an imminent health threat. Examples of the types of deficiencies, their level of severity, and correction priorities are discussed in Section 8 of this Report. 12.1.2

Regulatory Review

Depending on the jurisdiction and oversight process of regulatory agencies, the institution may be expected to review identified deficiencies against reporting criteria. This review should be appropriately documented, and required reports made to regulators according to the specified schedule. 63

64 / 12. DOCUMENTING DEFICIENCIES AND CORRECTIVE ACTIONS 12.1.3

Causal Analysis of Deficiencies

To prevent the recurrence of deficiencies, it is important to determine why a deficiency occurred. For example, if a particular task, process or program element is not being performed satisfactorily, it would be important to determine why the deficiency occurred (e.g., if staffing, training or procedures are inadequate). Answering the “why” questions regarding performance is necessary for correcting any deficiencies and improving the program. A specific example of the causal analysis process is the repeat analysis performed when medical x rays have to be retaken because the initial result was not satisfactory. Any exposure that has to be repeated is carefully evaluated to determine the deficiency. As an example, this process is documented in Compliance Guidance for Radiographic Quality Control issued by the New Jersey Department of Environmental Protection (NJDEP, 2003). If a deficiency is considered serious, the task, process or program owner should perform a causal analysis to determine how and why the deficiency occurred. Various approaches are available for doing such an analysis, but causal analysis should include a review of human factor considerations. Guidance on doing a causal analysis based on human factors issues was published by NRC (Barnes et al., 2001). Depending on the severity of the deficiency, a formal rootcause analysis may be warranted. Guidance on how to do a root-cause analysis is contained in the DOE Guideline: Root Cause Analysis Guidance Document (DOE, 1992). It discusses the typical causes of deficiencies including equipment failure, lack of management commitment, inadequate training, and human factors. 12.1.4

Isolated or Systemic Deficiencies

Identified deficiencies are often not isolated to single individuals, organizations or areas. By evaluating the extent of the deficiency across tasks, processes or program areas, radiation-safety personnel may identify systemic issues that warrant correction. Correcting a single deficiency may only treat a symptom, while the cure may be a process or program-wide improvement. 12.1.5

Development of Corrective Actions

A corrective-action plan should be developed for each of the deficiencies identified by the self assessment. This plan is typically developed by the individual or group responsible for performing the task, process or program element in which the deficiency was identified. Corrective actions should be prioritized so that the most serious deficiencies or those that present the greatest risk to the

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organization are given the highest priority. The corrective-action plan should identify the specific deficiency, the individual who has the overall responsibility for correcting the deficiency, and the schedule for resolving the deficiency. A single individual should be identified as responsible for the corrective action, even though the corrective action may require the actions of more than one individual. 12.1.6

Corrective-Action Completion

Completion of a corrective action should be documented, along with objective evidence of that completion. The completed action should be documented in the deficiency tracking and correctiveaction system. Management may wish to ensure closure with independent verification and a quality review of the corrective action. 12.1.7

Evaluation of Effectiveness of Corrective Actions

A corrective action may not address the root cause of a deficiency and further analysis may identify more appropriate corrective actions. Evaluation of the effectiveness of the corrective actions should be considered to ensure that the deficiencies have been corrected and to reestablish confidence in the task, process or program assessed. Ways to evaluate effectiveness include: • analysis of performance measures; • evaluation of new radiological incidents; • reassessment or surveillance of the deficient areas, including verification during the next scheduled self assessment; and • review documentation of process improvements such as manuals, procedures, and training records. The evaluation should identify those corrective actions that have been effective in resolving problems as well as those problems still needing resolution. A description of the deficiency, associated causes, and actions prescribed should be included. The effectiveness of corrective actions and their impacts on program performance should be considered. 12.2 Reviewing the Effectiveness of the Deficiency Tracking and Corrective-Action System In addition to evaluating the effectiveness of specific corrective actions the tracking and corrective-action system itself should be assessed periodically. Areas that can be assessed include:

66 / 12. DOCUMENTING DEFICIENCIES AND CORRECTIVE ACTIONS • Has a deficiency-tracking system been implemented? • Is a deficiency-tracking system required by regulations or other external commitment (e.g., contract)? • Are identified deficiencies entered into the deficiency tracking system in a timely manner? • Are deficiencies categorized appropriately based on their level of severity? • Are deficiencies resolved in a timely way based on their level of severity? • Is an individual responsible for resolving each deficiency identified? • Are corrective actions tracked to closure? • Does the system enable and record corrective-action effectiveness evaluations? • Is the deficiency-tracking system reviewed to identify generic program deficiencies? The institution should use feedback from assessments, corrective-action effectiveness evaluations, and deficiency tracking and corrective-action system reviews to look for areas for improvement. This feedback may drive the planning, scope or execution of future assessments and may drive changes in how identified deficiencies are resolved. This approach can help demonstrate and ensure the principle of continuous improvement in the radiation-safety program.

Appendix A Interview Guide for Task Assessments This guide provides suggestions for conducting interviews during task assessments. It is arranged into several categories of potential performance problem areas. The list of topics is not intended to be applicable to all tasks, particularly those of limited complexity or scope. Also, the intent is not to provide the interviewer with a list of questions that must be asked, but to suggest areas that could be probed during the interview process dependent upon the task being assessed. • Effectiveness of communications: - determine the extent of oral, written, or other types of communication governing the task; - determine if the instructions provided to the individual are adequate to perform the assigned task; - determine if there are any communication problems as a result of inconsistent communication practices; - if a communications policy for the task exists, determine if it is followed; and - if more than one work group is involved with the performance of the task, determine if the communications among the groups are adequate. • Effectiveness of the written documents used to perform the task: - determine if the procedures and other documents used during the task are technically accurate, appropriately sequenced, and sufficiently detailed to do the job correctly and safely; - determine if the documents used to conduct the task are clear and understood by the individual; - determine if the documents are used as required throughout the task (if they are not, determine why); 67

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determine if the individual finds it necessary to refer to another procedure that is not available on the job; - determine if the procedure is legible and up-to-date; - if any drawings, sketches or tables are used, determine if they are legible and up-to-date; - determine if the individual has any problems in obtaining the latest revision of any needed drawings or other documents such as technical manuals, data sheets, or figures; - determine if the procedure or work document used to perform the task lists the tools, materials and equipment needed to perform the task; - determine if the individual is aware of the potential consequences of not following the procedure for a particular task; and - determine the actions the individual would take if the task cannot be performed as required by the procedure or work document. • Facility issues: - determine if there are any problems in identifying the correct component to be worked on; - if there are problems in identifying the correct component, determine if/how the problem is resolved; - determine if the component operated or worked on is adequately labeled or tagged for identification; - determine if the labels and other identifiers are consistent with the facility identification system; and - determine if the controls and indicators used are in good condition, easily accessible, readable, and function as expected. • Work practices: - determine which of the following best describes how the individual uses the procedures during the task: - follows procedures verbatim step-by-step; - uses as a general guideline only; - reads before task, but not used much during task; - does not use during task because the procedure is confusing or omits steps; - does not use during task because there is a better way to do it; and - uses after the task to make sure nothing has been left out; - uses during the task because there are required signoffs or hold points; and

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does not use during task because it is too distracting to keep shifting back and forth from the task to the procedure. - determine if the tools and other equipment used on the job are available and in good working condition; - determine if the individual verifies the necessary prerequisite actions prior to starting the job and if this is required by procedure; and - determine if the individual verifies his/her action to make sure the task is performed correctly. • Work and supervision: - determine if the individual takes any shortcuts or reduces the amount of attentiveness devoted to the task because of unreasonable time restraints; - determine if the individual is required to perform tasks that should have been done by other groups; - if more than one person is needed to do the job, determine if help is available; - determine if there is enough time allowed to prepare for the task; - determine if the individual is assigned to more than one task at the same time; - before starting this job, determine if the individual is able to complete the task previously assigned; - determine if the duties and responsibilities regarding this task are clear to the individual; - if this task involves more than one group, determine if the groups are well coordinated; and - determine if the individual receives any unnecessary radiation exposure because of inadequate job planning. • Training: - determine if the individual is trained to perform the task; - determine if the training is based on actual tasks the individual performs; - determine if the individual thinks that the training is worthwhile; - determine if the individual has a good working knowledge of the equipment/systems; - determine if the individual has been trained to double check actions as a task is being performed; - determine if the individual is able to read and understand the drawings used for the task;

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determine if the instructors have the experience necessary to teach what needs to be taught to accomplish the task correctly; and - determine the last time training was conducted to maintain the job skill. • Plant management and administration: - determine if the individual is aware of the department goals and objectives and management's expectations/ standards related to the task; - determine if the individual has to report to more than one supervisor during the task; - determine if the responsibilities for the various aspects of this task are made clear to everyone involved; - determine if the reason for the job or work assignment is clear; - determine if the individual thinks that the task is within his/her capabilities; and - determine if supervisors visit the task area periodically.

Appendix B Examples of Self-Assessment Lines of Inquiry This appendix provides examples of lines of inquiry that could be used for performing self assessments on selected elements of a radiation-safety program. These examples are not intended to cover the list of possible elements of a radiation-safety program as outlined in Section 5.3. They are intended instead to serve as guidance for developing the specific lines of inquiry for the radiation-safety program elements at a specific institution. The radiation-safety program elements requiring assessment at a specific institution would depend on the nature, extent and complexity of the radiological activities. B.1 Adequacy of Worker Training and Qualifications B.1.1

Worker Training

This section provides guidance on assessing the training of workers in implementing the radiation-safety program. It covers the assessment of training course design and content, delivery, testing for retention, and periodic retraining. The radiation-safety training program should be described in the radiation-safety manual or program plan. The program should describe the target audiences requiring training, the job-task analyses used as the basis for course development, training design and development, lesson plans and training materials, instructor qualifications, evaluation and testing of students, course evaluation and feedback, and retraining/refresher training. Radiation-safety training programs are covered in detail in NCRP Report No. 134, Operational Radiation Safety Training (NCRP, 2000). In assessing the adequacy of the radiation-safety training program, the following should be considered: 71

72 / APPENDIX B • Adequacy and relevance of the job-task analyses used to support course development and content. Courses should have clearly stated learning objectives and should address the tasks identified in the job-task analyses. Review the lesson plans, training material, and testing/evaluation material for each course. • Records for approval of training course material and lesson plans, testing/evaluation of students, and completion of training courses. Periodic retraining and refresher training of workers should be reviewed as well. • Training classes and on-the-job training administered. Workers should also be observed performing radiological work tasks in the field. Both workers and instructors should be interviewed to obtain feedback and suggestions for improvement of the radiation-safety training program. • Status of retraining programs. These programs should be designed to ensure that a worker, once trained, continues to be qualified to conduct work assignments. B.1.2

Worker Qualifications

This section provides guidance on assessing the adequacy of worker qualifications for establishing and implementing an institution’s radiation-safety program. (This does not include assessing worker qualifications that are unrelated to their radiation-safety responsibilities.) Worker qualifications generally include the minimum levels of education, training and experience required to a specific job. The following are the steps that could be used to assess the adequacy of worker qualifications for implementing the radiationsafety program. 1.

Identify the categories of workers with responsibility for establishing or implementing some portion of the radiationsafety program. These categories range from workers with primary responsibility for the radiation-safety program to those workers whose radiation-safety responsibilities are peripheral to their primary work assignment. As described in NCRP Report No. 134 (NCRP, 2000), the general worker categories include: - radiation-safety personnel have the primary responsibility for establishing and implementing the radiationsafety program. This category includes health physicists, radiation-safety technicians, and workers responsible for

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implementing external and internal dosimetry programs. This category typically includes workers responsible for conducting radiation hazard analyses, operation of the radiation counting laboratory, providing radiation-safety training, calibrating and maintaining radiation survey meters, and conducting the environmental-monitoring program. - radiation workers may have a potential for exposure to ionizing radiation in the course of their work assignments. Although radiation safety will be a significant responsibility for these workers, it is not normally their primary work assignment. Examples of this category would include radiologists, glove-box workers, radiographers, medical and dental x-ray technicians, nuclear power plant workers, maintenance personnel who have to work on radioactively contaminated or activated equipment, researchers using radioactive materials, and emergency responders. - general workers have radiation-safety responsibilities that are peripheral to their primary job because their potential for exposure to radiation is minimal. Examples of this general worker category include security personnel, nurses, shipping clerks, firefighters, construction personnel, and students. - managers and supervisors have responsibility for the technical aspects of all or part of the radiation-safety program. It also includes those managers and supervisors who have subordinates in any worker category with radiation-safety program responsibilities. Managers and supervisors should ensure that their subordinates have the minimum qualifications for performing their work assignments. Determine whether appropriate written qualifications exist for the categories of workers identified in Step 1. The written qualifications should list the minimum job qualifications and the qualifications should be commensurate with the workers’ radiation-safety responsibilities. For example, a RSO at an academic, research and development laboratory should have a bachelor level degree in physical, chemical, biological sciences, or engineering and an appropriate level of training and experience in radiation protection (Fuller et al., 1999). For radiation program managers or RSOs responsible for large radiation-safety programs (e.g., national laboratory, large hospital complex, nuclear power plant) professional

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3.

certification in a related field (e.g., certification by the American Board of Health Physics, the American Board of Medical Physics, or the American Board of Radiology) is desirable. A researcher working with nuclear material should be trained and qualified as a radiation worker. A security officer should have a basic understanding of radiation and radiation protection, be able to interpret radiation warning signs, know how to respond to warning alarms, and know how to respond to emergencies. Federal and state regulations may require specific training for certain jobs and these requirements should be included in the written qualifications. For example, most states require that medical and dental x-ray technicians, nuclear-medicine technologists, and radiographers receive prescribed training and be licensed. Institution specific radiation-safety training requirements should be included in written job qualifications. The training requirements should be commensurate with the worker’s responsibilities. Typically, this training must be updated on a periodic basis. More information on radiation-safety training can be found in NCRP Report No. 134 (NCRP, 2000). Finally, many jobs have on-the-job training requirements. Typically, a less experienced worker is trained under the supervision of a qualified worker. For example, a less experienced radiation-safety technician may have to learn to use and interpret a survey meter in different radiation environments or change out a glove-box glove under the supervision of a more experienced radiation-safety technician. These on-the-job training requirements should be included in written job qualifications. Review the qualifications for individual workers in the categories identified in Step 1. Determine whether workers meet the minimum job qualifications as determined in Step 2 for their specific job including education, training (including retraining and on-the-job training), experience, and compliance with regulatory requirements. B.2 “As Low as Reasonably Achievable” Program

This section provides guidance that could be used in assessing the adequacy of the as low as reasonably achievable (ALARA) program. As defined in NCRP Report No. 127 (NCRP, 1998), the purpose of an ALARA program is to maintain occupational radiation doses as low as reasonably achievable below regulatory limits, economic and social factors being taken into account.

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Basic guidance for establishing an ALARA program is provided in Section 2 of NCRP Report No. 127 (NCRP, 1998). Other useful references are NCRP Report No. 107, Implementation of the Principle of As Low As Reasonably Achievable (ALARA) for Medical and Dental Personnel (NCRP, 1990) and NCRP Report No. 120, Dose Control at Nuclear Power Plants (NCRP, 1994); Standards for Protection Against Radiation (NRC, 2008a); and Radiation Protection Programs Guide (DOE, 2008b). Since an ALARA program does not require that specific radiation doses below regulatory limits be met, the assessment of an ALARA program will require the use of professional judgment by the assessor. Primary tasks will be to determine the existence of an ALARA program and whether reasonable procedures and processes to implement the program are in place. Although the basic principles of any ALARA program are the same, the specific details of an ALARA program depend on the nature of the operations, whether it be a nuclear power plant, hospital, national laboratory, university, industrial plant, or high-energy accelerator. For this reason, an assessor should have experience in the type of radiological operation being assessed (see Section 6 of this Report for guidance on qualifications of assessors). This section provides lines of inquiry for assessing the adequacy of the ALARA program that are applicable at most institutions. Areas to be assessed: • • • • • • • • • •

Is there a written ALARA program? Does the ALARA program require an annual report? Is an ALARA program a regulatory requirement? Is there a documented process for determining whether doses are ALARA? Are ALARA principles applied to all activities involving occupational exposure? Are workers trained in ALARA program requirements as they relate to their work assignment? Are ALARA considerations addressed during design reviews of modifications? Are ALARA considerations included in the work-planning process? Are patterns of occupational doses tracked by worker category? Is feedback sought from the workers on how to improve the ALARA program?

76 / APPENDIX B • Are unexpected radiation-monitoring or personal dosimetry results investigated to determine the cause? • Does management support and participate in the ALARA program? B.3 Engineered Safety Controls As discussed in Section 6.2 of NCRP Report No. 127 (NCRP, 1998), engineered safety controls are the preferred means for controlling radiation doses. In general, these include items that are permanently or semipermanently installed in a facility that are directly related to the operational radiation-safety program (e.g., fixed shielding, ventilation and filtration systems, fume hoods and glove boxes, radiation alarm and access-control systems, fixed airmonitoring equipment, radiation-monitoring systems, and remotehandling equipment). The discussion in this section focuses primarily on the operational characteristics of the engineered safety controls rather than on the specific design features. Specifically, this section provides guidance that could be used in assessing whether the engineered safety controls as designed, installed, operated and maintained are providing adequate safety protection. Although the performance of engineered safety controls and their design are interrelated, an evaluation of the design of engineered safety controls is normally done prior to starting up a facility, but can be a separate topic for an audit or self assessment. B.3.1

Shielding

Shielding is designed to reduce the potential for radiation exposure to workers and the public to some fraction of regulatory dose limits. The thickness, type of material, and placement of the shielding is determined by the type and intensity of the radiation being used. Useful references in preparing to self-assess the radiation shielding in a facility are NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998); NCRP Report No. 144, Radiation Protection for Particle Accelerators (NCRP, 2003); NCRP Report No.147, Structural Shielding Design for Medical X-Ray Imaging Facilities (NCRP, 2004); and NCRP Report No. 151, Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities (NCRP, 2005). Temporary shielding is discussed under Adequacy of Equipment in Appendix B.4. Specific questions that could be asked in assessing the adequacy of the radiation shielding in a facility include:

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• Is shielding adequate to reduce radiation in potentiallyoccupied areas to acceptable levels (both for occupationallyexposed workers and the general public) under all operating conditions? • Are penetrations adequately shielded? • Is the shielding appropriate for the types and sources of radiation present? • Has skyshine radiation been adequately shielded? • Is the shielding adequately secured so it will remain in its required configuration? • Is there adequate control of temporary shielding?

B.3.2

Ventilation and Filtration Systems

Ventilation systems are designed to control and contain the movement of airborne radioactive materials within the work area. The airflow is from areas of no or low airborne contamination to areas of higher airborne contamination. Filtration systems are used to capture the contamination before release to the environment. Useful references in preparing for self assessment of ventilation and filtration systems are Section 4.5 in NCRP Report No. 127 (NCRP, 1998) and Section 7.2.2.3 in NCRP Report No. 144 (NCRP, 2003). Other useful references include the Nuclear Air Cleaning Handbook (DOE, 2003) and the ACGIH Industrial Ventilation: A Manual of Recommended Practice (ACGIH, 2004). Questions that could be asked in performing a self assessment of the ventilation and filtration system include: • Is airflow from areas of lower to higher levels of contamination? • Is the pressure gradient sufficient to provide proper airflow during all conditions such as opening and closing room doors or entering a glove box? • Is the filtration system (or other contaminant removal systems) adequate to reduce effluents to acceptable levels? • Is there a preventive maintenance program for the ventilation and filtration systems? • Is the filtration system monitored as a source of radiation buildup? • Are the ventilation and filtration system adequately protected against fire, corrosive materials, and earthquakes?

78 / APPENDIX B B.3.3

Fume Hoods and Glove Boxes

Fume hoods and glove boxes are commonly used when handling dispersible radioactive material to reduce the potential for release of radioactivity into the work area. In general, glove boxes are used for handling high levels of alpha- or beta-emitting radionuclides. Useful references in preparing for self assessment of fume hoods and glove boxes are Section 4.5 in NCRP Report No. 127 (NCRP, 1998), Nuclear Air Cleaning Handbook (DOE, 2003), ACGIH Industrial Ventilation: A Manual of Recommended Practice (ACGIH, 2004), and Work Enclosures and Local Exhaust Systems for Toxic and Radioactive Material (LLNL, 2007). Questions that could be asked in performing a self assessment of fume hoods and glove-box systems include: • Is the type of enclosure suitable for the type, quantity and form of the radioactive material being handled? • Do fume hoods have appropriate airflow to confine the radioactive material during operations? Specifically, airflow should be adequate to contain the radioactive material, but not so high as to induce unnecessary turbulence. • Are fume hoods being operated properly? Specifically, are windows pulled down to the appropriate level during operations? In general, the inward airflow at the face of the hood should have a lineal velocity of 30.5 m min–1 (100 feet min–1). • Is pressure differential across a glove-box enclosure adequate to avoid overpressurizing the glove box when the worker enters? In general, the glove box should be able to maintain a negative pressure in the box of 0.635 cm (0.25 inches) on a water gauge. • Is the box adequately shielded to reduce doses to glove-box workers to acceptable levels? • Is there an alarm when the pressure differential in a glove box drops to an unacceptable level? • Is there a maintenance program to check for adequate air velocity across hood face openings? B.3.4

Radiation Alarm and Access-Control Systems

NCRP Report No. 88, Radiation Alarms and Access Control Systems (NCRP, 1986), defines and discusses recommendations for radiation alarm and access-control systems. A radiation alarm system alerts individuals to a potential or actual change in the working environment in real time. The alarm system may initiate

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mitigating actions, and may provide instructions (e.g., evacuation alarm or verbal announcement). Radiation alarms would include area monitors, air-monitoring systems, and criticality-monitoring systems. Access-control systems can also be used to verify that workers are qualified to be at a work location. Specifically, it should be ensured that workers have met all of the training, dosimetry, bioassay, and other procedural requirements necessary for entry into the area. An access-control system is to reduce the likelihood of unauthorized or inadvertent access to areas where high dose rates or high concentrations of radioactive material may be present during normal operations. Access-control systems include signs, lights, physical barriers, interlocks, run-safe switches, prestartup notifications, and emergency shutdown switches. Useful references are NCRP Report No. 144, Radiation Protection for Particle Accelerators (NCRP, 2003) and Radiation Protection Programs Guide (DOE, 2008b). Questions that could be asked in performing a self assessment of radiation alarm and access-control systems include: • Are radiation warning signs appropriate and adequately posted? • Are warning lights appropriate and their meaning clear? • Are physical barriers adequate and appropriately posted? • Are the interlocks, run-safe switches, and emergency shutdown switches tested on a periodic basis? • Is there a preventive maintenance program for alarm and access-control systems that have electrical or mechanical components? B.3.5

Air-Monitoring Equipment

Air monitors are continuously operating air samplers equipped with real-time detection devices to detect and provide a warning of any unexpected increase in airborne contamination. The type of air-monitoring system should be based on the type of radioactive material that is being handled and the detection level required. Guidance on air-monitoring systems is presented in Section 7.4.1 of NCRP Report No. 127 (NCRP, 1998). Questions that could be asked in performing a self assessment of air-monitoring systems include: • Are continuous air monitors located appropriately to detect unexpected releases of radioactive material? • Are alarm thresholds set to provide adequate warning and minimize false alarms?

80 / APPENDIX B • Are detectors calibrated at appropriate intervals? • Is there a preventive maintenance program for the air-monitoring equipment? B.3.6

Area-Monitoring Systems

Fixed area-monitoring systems are used when there is the possibility for a significant increase in ambient radiation levels in potentially-occupied areas. They would provide an alarm if a predetermined radiation dose rate is exceeded. Guidance on implementing area monitoring systems is presented in Section 6.4.2 of NCRP Report No. 127 (NCRP, 1998). Questions that could be asked in performing a self assessment of area-monitoring systems include: • Are radiation detectors located appropriately to detect unexpected increases in the ambient radiation level? • Are the radiation detectors appropriate for the type of radiation expected? • Are alarm thresholds set to provide adequate warning and minimize false alarms? • Are radiation detectors calibrated at appropriate intervals? • Is there a preventive maintenance program for the fixed radiation monitors? B.4 Adequacy of Equipment This section provides guidance on assessing the adequacy of the equipment used to implement the radiation-safety program. The equipment assessed in this section is generally portable, such as radiological-monitoring instrumentation, personnel protective equipment, temporary confinement, and shielding. Facility systems and fixed equipment (such as ventilation systems, fume hoods, glove boxes, and permanent shielding) are not included here and are covered under engineered controls. The radiological-monitoring instrument program should be described in the radiation-safety manual or program plan. The program should describe the methods used to select, calibrate, response check, maintain, and use radiological-monitoring instrumentation. The personnel dosimetry program should likewise be described in the radiation-safety manual, and should include similar topics. The general types of equipment used to implement the radiation-safety program can be found in NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998). Other references

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on radiation-monitoring instrumentation are NCRP Report No. 57, Instrumentation and Monitoring Methods for Radiation Protection (NCRP, 1978) and NCRP Report No. 112, Calibration of Survey Instruments Used in Radiation Protection for the Assessment of Ionizing Radiation Fields and Radioactive Surface Contamination (NCRP, 1991a). The following are the steps that should be used for assessing the adequacy of the equipment used to implement an institution’s radiation-safety program: • Identify the types of equipment needed to implement the radiation-safety program. • Determine whether radiological-monitoring instrumentation is appropriate for the types and energies of radiation present in the workplace. The instrumentation and equipment must also be appropriate for the environmental conditions under which they will be used. • Review the requirements for selection, use and calibration of the equipment. These include both regulatory requirements and other guidance adopted by the facility as the basis for the radiation-safety program, including regulatory guidance documents and international and national industry consensus standards. Determine the adequacy of implementation of these requirements in radiation-safety program documents and procedures. • Review the methods and currency of calibration and response checking of instruments. • Review the procedures for selection and use of the equipment, as well as maintenance and calibration (as applicable). • Review the availability of instrumentation and equipment to assess whether or not sufficient quantities are available for use. • Review the training and qualification program for user certification on the instrumentation and equipment. Review training requirements, content and method of delivery. • Observe workers using the equipment in the field and review the adequacy of use. A good practice is to question workers on the use of the equipment to obtain feedback on ease of use, problems with the equipment, and suggestions for improvement. • Is temporary shielding adequately configured, installed and controlled to prevent unauthorized removal?

82 / APPENDIX B B.5 Emergency Preparedness This section provides guidance on assessing preparedness for radiological emergencies. The development, implementation and evaluation of the facility radiation-safety emergency plan is discussed in NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998) and in more detail in NCRP Report No. 111, Developing Radiation Emergency Plans for Academic, Medical or Industrial Facilities (NCRP, 1991b). Assessment of the emergency preparedness program should include the review of the written emergency plan. The emergency plan should address the types of emergencies that could occur, the institutional structure, lines of authority and duties of individuals responding to an emergency, the training of responders, the training of employees to respond to emergencies, coordination with outside agencies, and the evaluation and testing of the plan. For more complex emergency plans, written procedures should have been developed to implement the plan. The assessment should review the periodic testing of the emergency plan, as well as the response to correct any identified deficiencies. B.6 Radiation-Source Accountability and Control Self-assessment programs should include evaluation of the control and security of radioactive material and sources. This includes control of both sealed and unsealed (dispersible) sources. This does not include the control and security of nuclear power plant fuel or quantities of special nuclear material for which a protective force is required. It also includes evaluating the control and security of radiation-generating equipment (x-ray machines or particle accelerators). The program for control of sealed sources and unsealed radioactive material should be described in the radiation-safety manual or program plan. The program should describe the methods used to receive, label, inventory, handle, store and dispose of sealed sources and unsealed radioactive material. In assessing the adequacy of the radioactive-material and sealed-source accountability and control program, the following should be considered: • inventory requirements for radioactive material and sealed radioactive sources [indicate receipt, physical location, ownership, date of last inventory, and leak test (as applicable)]; • procedures for the handling and control of radioactive sources and radioactive material (describe the methods for

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establishing and maintaining physical control and security of the radioactive material, the limitations on the use of the sealed source, the response to a leaking source, and the physical loss of a source); • procedures for handling, controlling, labeling and maintaining physical security for radioactive material and sources used by workers in the field; and • interviewing workers to obtain feedback and suggestions for improvement on radioactive-material and source handling and control and physical security measures. The program for accountability and control over radiationgenerating equipment should be similar to that for radioactive materials, and should similarly be described in the radiation-safety manual or program plan. This program should include periodic inventories of the equipment, handling and control procedures, and disposal or transfer requirements. Certain quantities of radioactive materials possessed by a licensee may be subject to increased controls about access and security, as described in the orders, regulations, or license conditions issued by NRC or its Agreement States (Strosnider, 2005). These controls not only describe the operational physical security provisions for those radioactive sources but also describe administrative restrictions about personnel and information relating to the sources. This section is not meant to describe all the special personnel or physical security provisions that these licensees are required to implement, but to give a general overview of these requirements. The increased security requirements that apply to a specific institution should be used as the basis of a self assessment of their implementation. Unescorted access to these sources may be granted to those individuals who require access to the sources to perform their duties and whose employment and educational histories and criminal background checks have been verified and documented as being satisfactory and who have been deemed trustworthy and reliable by the licensee. This includes not only the radiation-source operators (e.g., radiographers), but also those in management (Appendix B.1.2) who review the qualification documentation, such as human relations personnel. All other individuals require escorted access. These restrictions also apply to personnel who perform maintenance on the sources and their ancillary equipment, either in-house or through the services of a vendor. If a licensee uses a vendor, the licensee must have documentation that the vendor’s personnel have also met the increased security requirements. The

84 / APPENDIX B licensee is required to document the basis for concluding that there is reasonable assurance that the individual(s) are trustworthy and reliable and do not pose any unreasonable risk for unauthorized use of or access to the sources. Some of the operational and physical security provisions are meant to monitor continuously, detect immediately, and deter or delay unauthorized access to the sources. If unauthorized access is detected, then local law-enforcement agencies are to be notified immediately so they can respond promptly. These security requirements are also applicable to portable or mobile radioactive sources. Other controls are applicable to the shipment of these sources or devices. These include security controls that the carrier implements to prevent diversion of the source and prompt notification requirements in the event of a missing source or the delayed arrival of a source shipment. The documentation regarding qualified personnel, physical security plans, monitoring and detection equipment (and alarms), local law-enforcement response capabilities, etc., is to be limited to individuals who have the need to know the specific details of the security arrangements. It should also be noted that individual(s) selected to perform audits of the physical controls, personnel, or security documentation related to these radioactive sources must undergo the same security scrutiny before they are granted access to this sensitive information. B.7 Radiation-Safety Program Software This section provides general guidance on assessing the control and use of software used in the radiation-safety program. Typical types of software used in radiation-safety programs include radioactive-material inventory programs, internal and external dose calculation software, shielding codes, radioactive-material dispersion codes, and counting system software. Both commercially available software packages and those developed in-house should be subject to quality-assurance requirements and testing to ensure the user that the software is operating correctly and producing accurate results. The extent of this testing depends on the risk associated with the failure of the software. Verification testing is performed outside of the production environment and confirms that the code operates as intended. Validation testing confirms that the software meets the user’s needs and design requirements. Software should be subject to configuration management and control. Test data sets should be run periodically to confirm that the software is performing correctly.

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B.8 Worker Attitude Towards Radiation Safety This section provides guidance on assessing the general attitudes of the workers and management toward the radiation-safety program. Ultimately, the success of the radiation-safety program depends on the attitude of the worker towards his or her own safety. Section 3.5 of NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998), discusses this topic in more detail. Assessment of worker attitudes towards radiation safety is best accomplished by observation of work in the field and by worker interviews. Workers should demonstrate that radiation safety is an integral part of their work planning and execution, and that they take responsibility for minimizing their own dose. An atmosphere of cooperation between the radiation-safety organization and the workers should be evident, and radiation-safety measures should be viewed as integral to worker safety, as opposed to impediments to the execution of work. Both management and workers should show an understanding of the value of continuous improvement in the radiation-safety program. Workers and management should be aware of the goals of the radiation-safety program and the ALARA principle. B.9 Environmental Radiation Protection This section provides guidance on assessing the protection of the environment as an integral part of the radiation-safety program. It describes assessment of the program controlling offsite exposures including monitoring of liquid and air effluents, waste management, environmental monitoring, and assessment of dose to members of the public. A number of previous reports provide a discussion of environmental radiation-protection topics, which are summarized in NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998). In assessing the adequacy of the environmental radiation-safety program, the following should be reviewed: • adequacy of methods used to control offsite exposures, including facility shielding, confinement/ventilation systems, effluent treatment systems, and the program for release of potentially-contaminated materials and equipment (offsite exposures should be subject to the ALARA principle); and • program for monitoring offsite exposures to members of the public (the program and basis for monitoring of airborne

86 / APPENDIX B and liquid effluents should be examined, as well as environmental sampling, assessment of direct dose through environmental dosimetry, and calculation of doses to the public). B.10 Radioactive Waste Management NCRP Report No. 127 (NCRP, 1998) provides a summary of the radiation-safety aspects of managing radioactive waste. Report No. 127 is a useful reference to review when developing a selfassessment plan for radioactive waste-management operations. Radioactive waste is an unwanted byproduct of work with radioactive material; it should be managed so that its impacts are minimized. These impacts include radiation doses to workers during production, handling and storage, possible release to the environment, and the cost of disposal. Before beginning a self assessment of a radioactive waste-management program, it is necessary to determine the specific radionuclides (or mixtures of radionuclides) and the chemical and physical form of the radioactive material that is present in the waste. It is also necessary to know how the radioactive waste is handled, the volume of the radioactive waste, and the storage configuration. One particular area of concern is legacy radioactive waste. This is waste associated with a discontinued operation where the quantity, chemical and physical form of the radioactive material may not be well characterized and the adequacy of the containment uncertain. Because there can be several unknowns with legacy waste, it can be more hazardous than handling waste that is well characterized. There are several factors to consider when performing a self assessment of a radioactive waste-management program. These factors include: • Are there any significant occupational radiation doses associated with the handling, transfer or storage of radioactive waste? If so, what is being done to minimize the doses? • Are there provisions for minimizing the generation of waste, waste sorting and classification, segregation of waste by half-life for potential storage for decay, volume reduction, and recycle/reuse of equipment and tools? If so, are workers adequately trained in these techniques and procedures? • Is it possible that nonradioactive materials can be substituted for radioactive materials? If so, has it been determined that the substitute materials are not more hazardous than the radioactive material they are replacing?

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• What is the probability of creating radioactive hazardous waste and could material substitutions be made to reduce or eliminate the possibility? • Have the potential hazards of legacy waste been assessed? If so, what are the plans for dealing with the legacy waste? • Are radioactive wastes stored in proper containers so as to avoid the dispersal of these materials to the workplace or the environment under abnormal conditions? • Are there accurate records of the radioactive-waste inventory and the transfer of waste for disposal? B.11 Records This section provides guidance on assessing the generation, maintenance and retention of radiation-safety program records. NCRP Report No. 114, Maintaining Radiation Protection Records (NCRP, 1992) covers the contents of an adequate radiation-safety records program. Other useful references include NCRP Report No. 127, Operational Radiation Safety Program (NCRP, 1998), and Practice for Occupational Radiation Exposure Records Systems (ANSI/HPS, 1999). It is also important to include a review of applicable records when assessing individual program areas. In assessing the adequacy of the radiological records program, the following should be reviewed: • records program to verify that it is comprehensive in nature and includes the types of records described in NCRP Report No. 114 (NCRP, 1992); • design basis and maintenance of the radiological records system (records should be maintained in a format that facilitates retrieval, and that, if electronic, can be converted in the event that hardware/software platforms are upgraded; and the basis and selection of appropriate retention periods for records should be reviewed); and • adequacy of the physical protection program for records (records should be physically protected from environmental factors such as fire or water damage, and from theft or destruction and the assessor should also review the program for backup and storage of duplicate records).

Glossary as low as reasonably achievable (ALARA): A principle of radiationprotection philosophy that requires exposures to ionizing radiation to be kept as low a reasonably achievable, economic and social factors being taken into account. The protection from radiation exposure is ALARA when the expenditure of further resources would be unwarranted by the reduction in exposure that would be achieved. assessment: A review, evaluation, inspection, test, check, surveillance or audit to determine and document whether items, processes, systems or services meet specific requirements and are performing effectively. authorized users: Individuals who by virtue of required training, experience and qualifications are approved to perform specific tasks or operations. continuous improvement: The process of continually evaluating programs, processes and tasks with the objective of making them more effective and efficient. The process is a continuous loop of identifying and implementing possible improvements, providing feedback on the changes, and assessing the overall results of the program. corrective action: An action determined by an assessment team to be the most appropriate to fix the finding or problem or prevent recurrence of the problem. deficiency: (see finding). finding: Any condition or action that deviates from an applicable regulation, standard or procedure or adversely impacts the quality or reliability of any aspect of the radiation-safety program. inspection: Physical examination of equipment or a process to confirm that it meets the expectations of performance. institution: The management structure and its associated activities carried out at one or more sites; examples would include private industries, government research laboratories, hospitals, nuclear power plants, and universities. minor hazard: A hazard that has limited adverse impact on the radiation-safety program. moderate hazard: A hazard that has the potential to cause a radiation exposure in excess of regulatory dose limits, property damage, regulatory fines or penalties, or adverse public response. noteworthy practice: A practice that leads to the improvement in the effectiveness or efficiency of the radiation-safety program. Typically noteworthy practices exceed the requirements of the existing radiation-safety program. performance measure: The ongoing monitoring and reporting of program accomplishments, particularly progress towards preestablished goals. It is typically conducted by institutional or program management. A “program” may be any activity, project, function or policy that has an identifiable purpose or set of objectives.

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performance objective: Customer or management expectations for the effectiveness and performance of the task, process or program being evaluated. process: A series of actions that achieves an end result and usually includes two or more tasks. program: The integration of a set of processes and other activities that are planned, initiated and managed in a coordinated way to achieve desired results. Examples of programs are the internal/external dosimetry program, the self-assessment program, or the entire radiationsafety program. radiation-safety committee (RSC): The committee established at many academic and other institutions to provide oversight for the radiation-safety program and advice to the radiation-safety officer. Typically the members of the committee have institutional or program responsibilities for the use of radioactive materials or radiation-producing equipment at the institution. radiation-safety officer (RSO): The person directly responsible for the radiation-safety program. It is the RSO’s responsibility to ensure that the radiation-safety program is in compliance with regulations, standards, internal policy documents, implementing procedures, industry best practices, and goals. recommendation: Suggestion that, when implemented, could improve the performance and effectiveness of a task, process or program. risk assessment: An evaluation that considers both the consequences of a hazardous incident and the probability that the incident could occur. root cause: The reason for the occurrence of a deficiency or the failure of a process that when corrected will prevent recurrence. safety culture: The collective actions and attitudes of an institution and its workers which elevate the priority of safety issues to the proper level and encourage the adoption of the best available safety technology and standards-of-practice. serious hazard: A hazard that could result in injury or occupational illness, environmental harm, or property damage. self assessment: The process that an institution uses to critically review its own activities and performance in relation to regulations, standards, internal policy documents, implementing procedures, industry best practices, and goals. severe hazard: A hazard that has the potential to cause death, severe injury, or occupational illness, significant risk to the public, extensive environmental harm, or significant property damage. strength: A task, process or program that clearly results in positive performance beyond what is normally expected. team leader: An individual whose experience and training qualifies the person to direct an assessment and report assessment results. work: A defined task or activity such as operations; maintenance and repair; administration; safety software development, validation, testing and use; inspection; or data collection and analysis.

References ACGIH (2004). American Conference of Governmental Industrial Hygienists. Industrial Ventilation: A Manual of Recommended Practice, 25th ed. (American Conference of Governmental Industrial Hygienists, Cincinnati, Ohio). ANSI/AIHA (2006). American National Standards Institute/American Industrial Hygiene Association. Respiratory Protection – Respirator Use – Physical Qualifications for Personnel, Z88.6-2006 (American National Standards Institute, New York). ANSI/HPS (1999). American National Standards Institute/Health Physics Society. Practice for Occupational Radiation Exposure Records Systems, N13.6-1999 (Health Physics Society, McLean, Virginia). BARNES, V., HAAGENSEN, B. and O’HARA, J. (2001). “Evaluating the licensee’s root cause analysis,” Part 5 in The Human Performance Evaluation Process: A Resource for Reviewing the Identification and Resolution of Human Performance Problems, NUREG/CR-6751 (National Technical Information Service, Springfield, Virginia). DOE (1992). U.S. Department of Energy. DOE Guideline: Root Cause Analysis Guidance Document, DOE-NE-STD-1004-92 (National Technical Information Service, Springfield, Virginia). DOE (1997). U.S. Department of Energy. Implementation Guide for Use with DOE Order 225.1A, Accident Investigations, DOE G 225.1A-1 (U.S. Department of Energy, Washington). DOE (2003). U.S. Department of Energy. DOE Handbook: Nuclear Air Cleaning Handbook, DOE-HDBK-1169-2003 (U.S. Department of Energy, Washington). DOE (2004). U.S. Department of Energy. Safety of Accelerator Facilities, DOE O 420.2B (U.S. Department of Energy, Washington). DOE (2006). U.S. Department of Energy. Integrated Safety Management System Manual, DOE M 450.4-1 (U.S. Department of Energy, Washington). DOE (2008a). U.S. Department of Energy. Occupational Radiation Protection, 10 CFR 835 (U.S. Government Printing Office, Washington). DOE (2008b). U.S. Department of Energy. Radiation Protection Programs Guide for Use with Title 10, Code of Federal Regulations, Part 835, Occupational Radiation Protection, DOE G 441.1-1C (U.S. Department of Energy, Washington). EPA (2000). U.S. Environmental Protection Agency. “Incentives for self-policing: discovery, disclosure, correcting and prevention of violations,” 65 FR 19618–19627 (U.S. Environmental Protection Agency, Washington).

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FULLER, M.L., HAYS, R.P., LODHI, A.S. and PURDY, G.W. (1999). “Sample audit program,” Appendix L in Consolidated Guidance About Materials Licenses: Program-Specific Guidance About Academic, Research and Development, and Other Licenses of Limited Scope, Including Gas Chromatographs and X-Ray Fluorescence Analyzers: Final Report, NUREG-1556-V7 (National Technical Information Service, Springfield, Virginia). IAEA (2002). International Atomic Energy Agency. Safety Culture in Nuclear Installations: Guidance for Use in the Enhancement of Safety Culture, IAEA-TECDOC-1329 (International Atomic Energy Agency, Vienna). IAEA (2005). International Atomic Energy Agency. Categorization of Radioactive Sources, IAEA Safety Standards Series No. RS-G-1.9 (International Atomic Energy Agency, Vienna). LLNL (2007). Lawrence Livermore National Laboratory. “Work enclosures and local exhaust systems for toxic and radioactive materials,” Document 12.4 in Environment, Safety and Health Manual (Lawrence Livermore Laboratory, Livermore, California). MICHEL, R., JACOB, N., MILLER, K. and ZORN, M. (2005). “Riskinformed, performance-based inspections at medical facilities [A guide to SI units in radiation protection: Operational topic],” Health Phys. 88(5) S69–S72. NCRP (1978). National Council on Radiation Protection and Measurements. Instrumentation and Monitoring Methods for Radiation Protection, NCRP Report No. 57 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1986). National Council on Radiation Protection and Measurements. Radiation Alarms and Access Control Systems, NCRP Report No. 88 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1990). National Council on Radiation Protection and Measurements. Implementation of the Principle of As Low As Reasonably Achievable (ALARA) for Medical and Dental Personnel, NCRP Report No. 107 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1991a). National Council on Radiation Protection and Measurements. Calibration of Survey Instruments Used in Radiation Protection for the Assessment of Ionizing Radiation Fields and Radioactive Surface Contamination, NCRP Report No. 112 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1991b). National Council on Radiation Protection and Measurements. Developing Radiation Emergency Plans for Academic, Medical or Industrial Facilities, NCRP Report No. 111 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1992). National Council on Radiation Protection and Measurements. Maintaining Radiation Protection Records, NCRP Report No. 114 (National Council on Radiation Protection and Measurements, Bethesda, Maryland).

92 / REFERENCES NCRP (1994). National Council on Radiation Protection and Measurements. Dose Control at Nuclear Power Plants, NCRP Report No. 120 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (1998). National Council on Radiation Protection and Measurements. Operational Radiation Safety Program, NCRP Report No. 127 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (2000). National Council on Radiation Protection and Measurements. Operational Radiation Safety Training, NCRP Report No. 134 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (2003). National Council on Radiation Protection and Measurements. Radiation Protection for Particle Accelerators, NCRP Report No. 144 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (2004). National Council on Radiation Protection and Measurements. Structural Shielding Design for Medical X-Ray Imaging Facilities, NCRP Report No. 147 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NCRP (2005). National Council on Radiation Protection and Measurements. Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities, NCRP Report No. 151 (National Council on Radiation Protection and Measurements, Bethesda, Maryland). NIST (1987). National Institute of Standards and Technology. The Malcolm Baldrige National Quality Improvement Act of 1987, Public Law 100-107, http://www.quality.nist.gov/Improve- ment_Act.htm (accessed December 7, 2009) (National Institute of Standards and Technology, Gaithersburg, Maryland). NJDEP (2003). New Jersey Department of Environmental Protection. Compliance Guidance for Radiographic Quality Control, 4th ed. (New Jersey Department of Environmental Protection, Trenton, New Jersey) NRC (1997). U.S. Nuclear Regulatory Commission. Volume 8: License Oversight Programs AEOD. Accident Investigation Directive 8.9 (U.S. Nuclear Regulatory Commission, Washington). NRC (2005). U.S. Nuclear Regulatory Commission. NRC Regulatory Issue Summary 2005-18, Guidance for Establishing and Maintaining a Safety Conscious Work Environment (U.S. Nuclear Regulatory Commission, Washington). NRC (2007). U.S. Nuclear Regulatory Commission. Schedule B. Rules of General Applicability to Domestic Licensing of Byproduct Material, 10 CFR 30.71 (U.S. Nuclear Regulatory Commission, Washington). NRC (2008a). U.S. Nuclear Regulatory Commission. Radiation Protection Programs. Standards for Protection Against Radiation, 10 CFR 20.1101 Subpart B (U.S. Government Printing Office, Washington).

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NRC (2008b). U.S. Nuclear Regulatory Commission. “Revision of the NRC enforcement policy,” 73 FR 72528–72529 (U.S. Government Printing Office, Washington). NRC (2008c). U.S. Nuclear Regulatory Commission. “Quality assurance criteria for nuclear power plants and fuel reprocessing plants,” Appendix B in Domestic Licensing of Production and Utilization Facilities, 10 CFR 50 (U.S. Nuclear Regulatory Commission, Washington). OSHA (2000). Occupational Safety and Health Administration. “Final policy concerning the Occupational Safety and Health Administration’s treatment of voluntary employer safety and health self-audits,” 65 FR 46498–46503 (U.S. Government Printing Office, Washington). STALNAKER, C.K. (1996). “Line management self-assessment of safety performance,” Prof. Saf. (August) 32–34. STROSNIDER, J.R. (2005). Issuance of Order for Enhanced Security Measures for Certain Radioactive Materials Licenees, EA-05-090, http://www.nrc.gov/reading-rm/doc-collections/commission/commsecy/2005/2005-0019 comscy-attachment1.pdf (accessed December 7, 2009) (U.S. Nuclear Regulatory Commission, Washington). VESELY, W.E., GOLDBERG, F.F., ROBERTS, N.H. and HAASL, D.F. (1981). Fault Tree Handbook, NUREG-0492 (National Technical Information Service, Springfield, Virginia).

The NCRP The National Council on Radiation Protection and Measurements is a nonprofit corporation chartered by Congress in 1964 to: 1. Collect, analyze, develop and disseminate in the public interest information and recommendations about (a) protection against radiation and (b) radiation measurements, quantities and units, particularly those concerned with radiation protection. 2. Provide a means by which organizations concerned with the scientific and related aspects of radiation protection and of radiation quantities, units and measurements may cooperate for effective utilization of their combined resources, and to stimulate the work of such organizations. 3. Develop basic concepts about radiation quantities, units and measurements, about the application of these concepts, and about radiation protection. 4. Cooperate with the International Commission on Radiological Protection, the International Commission on Radiation Units and Measurements, and other national and international organizations, governmental and private, concerned with radiation quantities, units and measurements and with radiation protection. The Council is the successor to the unincorporated association of scientists known as the National Committee on Radiation Protection and Measurements and was formed to carry on the work begun by the Committee in 1929. The participants in the Council’s work are the Council members and members of scientific and administrative committees. Council members are selected solely on the basis of their scientific expertise and serve as individuals, not as representatives of any particular organization. The scientific committees, composed of experts having detailed knowledge and competence in the particular area of the committee's interest, draft proposed recommendations. These are then submitted to the full membership of the Council for careful review and approval before being published. The following comprise the current officers and membership of the Council:

Officers President Senior Vice President Secretary and Treasurer

Thomas S. Tenforde Kenneth R. Kase David A. Schauer

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Members John F. Ahearne Edward S. Amis, Jr. Sally A. Amundson Kimberly E. Applegate Benjamin R. Archer Stephen Balter Steven M. Becker Joel S. Bedford Mythreyi Bhargavan Eleanor A. Blakely William F. Blakely Wesley E. Bolch Thomas B. Borak Andre Bouville Leslie A. Braby David J. Brenner James A. Brink Brooke R. Buddemeier Jerrold T. Bushberg John F. Cardella Charles E. Chambers Polly Y. Chang S.Y. Chen Mary E. Clark Michael L. Corradini Allen G. Croff Paul M. DeLuca Christine A. Donahue David A. Eastmond Stephen A. Feig Alan J. Fischman Patricia A. Fleming John R. Frazier

Donald P. Frush Ronald E. Goans Robert L. Goldberg Raymond A. Guilmette Roger W. Harms Kathryn Held F. Owen Hoffman Roger W. Howell Timothy J. Jorgensen Kenneth R. Kase Ann R. Kennedy William E. Kennedy, Jr. David C. Kocher Ritsuko Komaki Amy Kronenberg Susan M. Langhorst Edwin M. Leidholdt Howard L. Liber James C. Lin Jill A. Lipoti Paul A. Locke Jay H. Lubin C. Douglas Maynard Debra McBaugh Ruth E. McBurney Fred A. Mettler, Jr. Charles W. Miller Donald L. Miller William H. Miller William F. Morgan Stephen V. Musolino David S. Myers Bruce A. Napier Gregory A. Nelson

Andrea K. Ng Carl J. Paperiello Terry C. Pellmar R. Julian Preston Jerome C. Puskin Abram Recht Michael T. Ryan Adela Salame-Alfie Beth A. Schueler Thomas M. Seed J. Anthony Seibert Stephen M. Seltzer Edward A. Sickles Steven L. Simon Paul Slovic Christopher G. Soares Daniel J. Strom Thomas S. Tenforde Julie E.K. Timins Richard E. Toohey Lawrence W. Townsend Elizabeth L. Travis Fong Y. Tsai Richard J. Vetter Chris G. Whipple Robert C. Whitcomb, Jr. Stuart C. White Gayle E. Woloschak Shiao Y. Woo Andrew J. Wyrobek X. George Xu R. Craig Yoder Marco A. Zaider

Distinguished Emeritus Members Warren K. Sinclair, President Emeritus; Charles B. Meinhold, President Emeritus S. James Adelstein, Honorary Vice President W. Roger Ney, Executive Director Emeritus William M. Beckner, Executive Director Emeritus Seymour Abrahamson R.J. Michael Fry Dade W. Moeller Lynn R. Anspaugh Thomas F. Gesell A. Alan Moghissi John A. Auxier Ethel S. Gilbert Wesley L. Nyborg William J. Bair Robert O. Gorson John W. Poston, Sr. Harold L. Beck Joel E. Gray Andrew K. Poznanski Bruce B. Boecker Arthur W. Guy Genevieve S. Roessler John D. Boice, Jr. Eric J. Hall Marvin Rosenstein Robert L. Brent Naomi H. Harley Lawrence N. Rothenberg Antone L. Brooks William R. Hendee Henry D. Royal Randall S. Caswell Donald G. Jacobs William J. Schull J. Donald Cossairt Bernd Kahn Roy E. Shore James F. Crow Charles E. Land John E. Till Gerald D. Dodd John B. Little Robert L. Ullrich Sarah S. Donaldson Roger O. McClellan Arthur C. Upton William P. Dornsife Barbara J. McNeil F. Ward Whicker Keith F. Eckerman Kenneth L. Miller Susan D. Wiltshire Thomas S. Ely Marvin C. Ziskin

96 / THE NCRP Lauriston S. Taylor Lecturers John D. Boice, Jr. (2009) Radiation Epidemiology: The Golden Age and Remaining Challenges Dade W. Moeller (2008) Radiation Standards, Dose/Risk Assessments, Public Interactions, and Yucca Mountain: Thinking Outside the Box Patricia W. Durbin (2007) The Quest for Therapeutic Actinide Chelators Robert L. Brent (2006) Fifty Years of Scientific Research: The Importance of Scholarship and the Influence of Politics and Controversy John B. Little (2005) Nontargeted Effects of Radiation: Implications for Low-Dose Exposures Abel J. Gonzalez (2004) Radiation Protection in the Aftermath of a Terrorist Attack Involving Exposure to Ionizing Radiation Charles B. Meinhold (2003) The Evolution of Radiation Protection: From Erythema to Genetic Risks to Risks of Cancer to ? R. Julian Preston (2002) Developing Mechanistic Data for Incorporation into Cancer Risk Assessment: Old Problems and New Approaches Wesley L. Nyborg (2001) Assuring the Safety of Medical Diagnostic Ultrasound S. James Adelstein (2000) Administered Radioactivity: Unde Venimus Quoque Imus Naomi H. Harley (1999) Back to Background Eric J. Hall (1998) From Chimney Sweeps to Astronauts: Cancer Risks in the Workplace William J. Bair (1997) Radionuclides in the Body: Meeting the Challenge! Seymour Abrahamson (1996) 70 Years of Radiation Genetics: Fruit Flies, Mice and Humans Albrecht Kellerer (1995) Certainty and Uncertainty in Radiation Protection R.J. Michael Fry (1994) Mice, Myths and Men Warren K. Sinclair (1993) Science, Radiation Protection and the NCRP Edward W. Webster (1992) Dose and Risk in Diagnostic Radiology: How Big? How Little? Victor P. Bond (1991) When is a Dose Not a Dose? J. Newell Stannard (1990) Radiation Protection and the Internal Emitter Saga Arthur C. Upton (1989) Radiobiology and Radiation Protection: The Past Century and Prospects for the Future Bo Lindell (1988) How Safe is Safe Enough? Seymour Jablon (1987) How to be Quantitative about Radiation Risk Estimates Herman P. Schwan (1986) Biological Effects of Non-ionizing Radiations: Cellular Properties and Interactions John H. Harley (1985) Truth (and Beauty) in Radiation Measurement Harald H. Rossi (1984) Limitation and Assessment in Radiation Protection Merril Eisenbud (1983) The Human Environment—Past, Present and Future Eugene L. Saenger (1982) Ethics, Trade-Offs and Medical Radiation James F. Crow (1981) How Well Can We Assess Genetic Risk? Not Very Harold O. Wyckoff (1980) From “Quantity of Radiation” and “Dose” to “Exposure” and “Absorbed Dose”—An Historical Review Hymer L. Friedell (1979) Radiation Protection—Concepts and Trade Offs Sir Edward Pochin (1978) Why be Quantitative about Radiation Risk Estimates? Herbert M. Parker (1977) The Squares of the Natural Numbers in Radiation Protection

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Currently, the following committees are actively engaged in formulating recommendations:

Program Area Committee 1: Basic Criteria, Epidemiology, Radiobiology, and Risk SC 1-13 Impact of Individual Susceptibility and Previous Radiation Exposure on Radiation Risk for Astronauts SC 1-15 Radiation Safety in NASA Lunar Missions’ SC 1-16 Uncertainties in the Estimation of Radiation Risks and Probability of Disease Causation SC 1-17 Second Cancers and Cardiopulmonary Effects After Radiotherapy SC 1-18 Use of Ionizing Radiation Screen Systems for Detection of Radioactive Materials that Could Represent a Threat to Homeland Security SC 1-19 Health Protection Issues Associated with Use of Active Detection Technology Security Systems for Detection of Radioactive Threat Materials SC 85 Risk of Lung Cancer from Radon

Program Area Committee 2: Operational Radiation Safety SC 2-2 Key Decision Points and Information Needed by Decision Makers in the Aftermath of a Nuclear or Radiological Terrorism Incident SC 2-3 Radiation Safety Issues for Image-Guided Interventional Medical Procedures

Program Area Committee 3: Nuclear and Radiological Security and Safety Program Area Committee 4: Radiation Protection in Medicine SC 4-2 Population Monitoring and Decontamination Following a Nuclear/ Radiological Incident SC 4-3 Diagnostic Reference Levels in Medical Imaging: Recommendations for Application in the United States SC 4-4 Risks of Ionizing Radiation to the Developing Embryo, Fetus and Nursing Infant

Program Area Committee 5: Environmental Radiation and Radioactive Waste Issues SC 64-22 Design of Effective Effluent and Environmental Monitoring Programs

Program Area Committee 6: Radiation Measurements and Dosimetry In recognition of its responsibility to facilitate and stimulate cooperation among organizations concerned with the scientific and related aspects of radiation protection and measurement, the Council has created a category of NCRP Collaborating Organizations. Organizations or groups of organizations that are national or international in scope and are concerned with scientific problems involving radiation quantities, units, measurements and effects, or radiation protection may be admitted to collaborating status by the Council. Collaborating Organizations provide a means by which NCRP can gain input into its activities from a wider segment of society. At the same time, the relationships with the Collaborating Organizations facilitate wider dissemination of information about the Council's activities, interests and concerns. Collaborating Organizations have the opportunity to comment on draft reports (at the time

98 / THE NCRP that these are submitted to the members of the Council). This is intended to capitalize on the fact that Collaborating Organizations are in an excellent position to both contribute to the identification of what needs to be treated in NCRP reports and to identify problems that might result from proposed recommendations. The present Collaborating Organizations with which NCRP maintains liaison are as follows: American Academy of Dermatology American Academy of Environmental Engineers American Academy of Health Physics American Academy of Orthopaedic Surgeons American Association of Physicists in Medicine American Bracytherapy Society American College of Cardiology American College of Medical Physics American College of Nuclear Physicians American College of Occupational and Environmental Medicine American College of Radiology American Conference of Governmental Industrial Hygienists American Dental Association American Industrial Hygiene Association American Institute of Ultrasound in Medicine American Medical Association American Nuclear Society American Pharmaceutical Association American Podiatric Medical Association American Public Health Association American Radium Society American Roentgen Ray Society American Society for Radiation Oncology American Society of Emergency Radiology American Society of Health-System Pharmacists American Society of Nuclear Cardiology American Society of Radiologic Technologists Association of Educators in Imaging and Radiological Sciences Association of University Radiologists Bioelectromagnetics Society Campus Radiation Safety Officers College of American Pathologists Conference of Radiation Control Program Directors, Inc. Council on Radionuclides and Radiopharmaceuticals Defense Threat Reduction Agency Electric Power Research Institute Federal Aviation Administration Federal Communications Commission Federal Emergency Management Agency Genetics Society of America Health Physics Society Institute of Electrical and Electronics Engineers, Inc. Institute of Nuclear Power Operations International Brotherhood of Electrical Workers

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National Aeronautics and Space Administration National Association of Environmental Professionals National Center for Environmental Health/Agency for Toxic Substances National Electrical Manufacturers Association National Institute for Occupational Safety and Health National Institute of Standards and Technology Nuclear Energy Institute Office of Science and Technology Policy Paper, Allied-Industrial, Chemical and Energy Workers International Union Product Stewardship Institute Radiation Research Society Radiological Society of North America Society for Cardiovascular Angiography and Interventions Society for Pediatric Radiology Society for Risk Analysis Society of Cardiovascular Computed Tomography Society of Chairmen of Academic Radiology Departments Society of Interventional Radiology Society of Nuclear Medicine Society of Radiologists in Ultrasound Society of Skeletal Radiology U.S. Air Force U.S. Army U.S. Coast Guard U.S. Department of Energy U.S. Department of Housing and Urban Development U.S. Department of Labor U.S. Department of Transportation U.S. Environmental Protection Agency U.S. Navy U.S. Nuclear Regulatory Commission U.S. Public Health Service Utility Workers Union of America NCRP has found its relationships with these organizations to be extremely valuable to continued progress in its program. Another aspect of the cooperative efforts of NCRP relates to the Special Liaison relationships established with various governmental organizations that have an interest in radiation protection and measurements. This liaison relationship provides: (1) an opportunity for participating organizations to designate an individual to provide liaison between the organization and NCRP; (2) that the individual designated will receive copies of draft NCRP reports (at the time that these are submitted to the members of the Council) with an invitation to comment, but not vote; and (3) that new NCRP efforts might be discussed with liaison individuals as appropriate, so that they might have an opportunity to make suggestions on new studies and related matters. The following organizations participate in the Special Liaison Program: Australian Radiation Laboratory Bundesamt fur Strahlenschutz (Germany)

100 / THE NCRP Canadian Nuclear Safety Commission Central Laboratory for Radiological Protection (Poland) China Institute for Radiation Protection Commissariat a l’Energie Atomique (France) Commonwealth Scientific Instrumentation Research Organization (Australia) European Commission Health Council of the Netherlands Health Protection Agency International Commission on Non-ionizing Radiation Protection International Commission on Radiation Units and Measurements International Commission on Radiological Protection International Radiation Protection Association Japanese Nuclear Safety Commission Japan Radiation Council Korea Institute of Nuclear Safety Russian Scientific Commission on Radiation Protection South African Forum for Radiation Protection World Association of Nuclear Operators World Health Organization, Radiation and Environmental Health NCRP values highly the participation of these organizations in the Special Liaison Program. The Council also benefits significantly from the relationships established pursuant to the Corporate Sponsor's Program. The program facilitates the interchange of information and ideas and corporate sponsors provide valuable fiscal support for the Council's program. This developing program currently includes the following Corporate Sponsors: 3M GE Healthcare Global Dosimetry Solutions, Inc. Landauer, Inc. Nuclear Energy Institute The Council's activities have been made possible by the voluntary contribution of time and effort by its members and participants and the generous support of the following organizations: 3M Health Physics Services Agfa Corporation Alfred P. Sloan Foundation Alliance of American Insurers American Academy of Dermatology American Academy of Health Physics American Academy of Oral and Maxillofacial Radiology American Association of Physicists in Medicine American Cancer Society American College of Medical Physics American College of Nuclear Physicians American College of Occupational and Environmental Medicine

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American College of Radiology American College of Radiology Foundation American Dental Association American Healthcare Radiology Administrators American Industrial Hygiene Association American Insurance Services Group American Medical Association American Nuclear Society American Osteopathic College of Radiology American Podiatric Medical Association American Public Health Association American Radium Society American Roentgen Ray Society American Society for Radiation Oncology American Society for Therapeutic Radiology and Oncology American Society of Radiologic Technologists American Veterinary Medical Association American Veterinary Radiology Society Association of Educators in Radiological Sciences, Inc. Association of University Radiologists Battelle Memorial Institute Canberra Industries, Inc. Chem Nuclear Systems Center for Devices and Radiological Health College of American Pathologists Committee on Interagency Radiation Research and Policy Coordination Commonwealth Edison Commonwealth of Pennsylvania Consolidated Edison Consumers Power Company Council on Radionuclides and Radiopharmaceuticals Defense Nuclear Agency Defense Threat Reduction Agency Duke Energy Corporation Eastman Kodak Company Edison Electric Institute Edward Mallinckrodt, Jr. Foundation EG&G Idaho, Inc. Electric Power Research Institute Electromagnetic Energy Association Federal Emergency Management Agency Florida Institute of Phosphate Research Florida Power Corporation Fuji Medical Systems, U.S.A., Inc. Genetics Society of America Global Dosimetry Solutions Health Effects Research Foundation (Japan) Health Physics Society ICN Biomedicals, Inc. Institute of Nuclear Power Operations

102 / THE NCRP James Picker Foundation Martin Marietta Corporation Motorola Foundation National Aeronautics and Space Administration National Association of Photographic Manufacturers National Cancer Institute National Electrical Manufacturers Association National Institute of Standards and Technology New York Power Authority Philips Medical Systems Picker International Public Service Electric and Gas Company Radiation Research Society Radiological Society of North America Richard Lounsbery Foundation Sandia National Laboratory Siemens Medical Systems, Inc. Society of Nuclear Medicine Society of Pediatric Radiology Southern California Edison Company U.S. Department of Energy U.S. Department of Labor U.S. Environmental Protection Agency U.S. Navy U.S. Nuclear Regulatory Commission Victoreen, Inc. Westinghouse Electric Corporation Initial funds for publication of NCRP reports were provided by a grant from the James Picker Foundation. NCRP seeks to promulgate information and recommendations based on leading scientific judgment on matters of radiation protection and measurement and to foster cooperation among organizations concerned with these matters. These efforts are intended to serve the public interest and the Council welcomes comments and suggestions on its reports or activities.

NCRP Publications NCRP publications can be obtained online in both hard- and soft-copy (downloadable PDF) formats at http://NCRPpublications.org. Professional societies can arrange for discounts for their members by contacting NCRP. Additional information on NCRP publications may be obtained from the NCRP website (http://NCRPonline.org) or by telephone (800-229-2652, ext. 25) and fax (301-907-8768). The mailing address is: NCRP Publications 7910 Woodmont Avenue Suite 400 Bethesda, MD 20814-3095 Abstracts of NCRP reports published since 1980, abstracts of all NCRP commentaries, and the text of all NCRP statements are available at the NCRP website. Currently available publications are listed below.

NCRP Reports No.

Title 8 22

25 27 30 32 35 36 37 38 40 41 42 44 46

Control and Removal of Radioactive Contamination in Laboratories (1951) Maximum Permissible Body Burdens and Maximum Permissible Concentrations of Radionuclides in Air and in Water for Occupational Exposure (1959) [includes Addendum 1 issued in August 1963] Measurement of Absorbed Dose of Neutrons, and of Mixtures of Neutrons and Gamma Rays (1961) Stopping Powers for Use with Cavity Chambers (1961) Safe Handling of Radioactive Materials (1964) Radiation Protection in Educational Institutions (1966) Dental X-Ray Protection (1970) Radiation Protection in Veterinary Medicine (1970) Precautions in the Management of Patients Who Have Received Therapeutic Amounts of Radionuclides (1970) Protection Against Neutron Radiation (1971) Protection Against Radiation from Brachytherapy Sources (1972) Specification of Gamma-Ray Brachytherapy Sources (1974) Radiological Factors Affecting Decision-Making in a Nuclear Attack (1974) Krypton-85 in the Atmosphere—Accumulation, Biological Significance, and Control Technology (1975) Alpha-Emitting Particles in Lungs (1975)

103

104 / NCRP PUBLICATIONS 47 49 50 52 54 55 57 58 60 61 62 63 64 65 67 68 69 70 72 73 74 75 76

77 78 79 80 81 82

Tritium Measurement Techniques (1976) Structural Shielding Design and Evaluation for Medical Use of X Rays and Gamma Rays of Energies Up to 10 MeV (1976) Environmental Radiation Measurements (1976) Cesium-137 from the Environment to Man: Metabolism and Dose (1977) Medical Radiation Exposure of Pregnant and Potentially Pregnant Women (1977) Protection of the Thyroid Gland in the Event of Releases of Radioiodine (1977) Instrumentation and Monitoring Methods for Radiation Protection (1978) A Handbook of Radioactivity Measurements Procedures, 2nd ed. (1985) Physical, Chemical, and Biological Properties of Radiocerium Relevant to Radiation Protection Guidelines (1978) Radiation Safety Training Criteria for Industrial Radiography (1978) Tritium in the Environment (1979) Tritium and Other Radionuclide Labeled Organic Compounds Incorporated in Genetic Material (1979) Influence of Dose and Its Distribution in Time on Dose-Response Relationships for Low-LET Radiations (1980) Management of Persons Accidentally Contaminated with Radionuclides (1980) Radiofrequency Electromagnetic Fields—Properties, Quantities and Units, Biophysical Interaction, and Measurements (1981) Radiation Protection in Pediatric Radiology (1981) Dosimetry of X-Ray and Gamma-Ray Beams for Radiation Therapy in the Energy Range 10 keV to 50 MeV (1981) Nuclear Medicine—Factors Influencing the Choice and Use of Radionuclides in Diagnosis and Therapy (1982) Radiation Protection and Measurement for Low-Voltage Neutron Generators (1983) Protection in Nuclear Medicine and Ultrasound Diagnostic Procedures in Children (1983) Biological Effects of Ultrasound: Mechanisms and Clinical Implications (1983) Iodine-129: Evaluation of Releases from Nuclear Power Generation (1983) Radiological Assessment: Predicting the Transport, Bioaccumulation, and Uptake by Man of Radionuclides Released to the Environment (1984) Exposures from the Uranium Series with Emphasis on Radon and Its Daughters (1984) Evaluation of Occupational and Environmental Exposures to Radon and Radon Daughters in the United States (1984) Neutron Contamination from Medical Electron Accelerators (1984) Induction of Thyroid Cancer by Ionizing Radiation (1985) Carbon-14 in the Environment (1985) SI Units in Radiation Protection and Measurements (1985)

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83 The Experimental Basis for Absorbed-Dose Calculations in Medical Uses of Radionuclides (1985) 84 General Concepts for the Dosimetry of Internally Deposited Radionuclides (1985) 86 Biological Effects and Exposure Criteria for Radiofrequency Electromagnetic Fields (1986) 87 Use of Bioassay Procedures for Assessment of Internal Radionuclide Deposition (1987) 88 Radiation Alarms and Access Control Systems (1986) 89 Genetic Effects from Internally Deposited Radionuclides (1987) 90 Neptunium: Radiation Protection Guidelines (1988) 92 Public Radiation Exposure from Nuclear Power Generation in the United States (1987) 93 Ionizing Radiation Exposure of the Population of the United States (1987) 94 Exposure of the Population in the United States and Canada from Natural Background Radiation (1987) 95 Radiation Exposure of the U.S. Population from Consumer Products and Miscellaneous Sources (1987) 96 Comparative Carcinogenicity of Ionizing Radiation and Chemicals (1989) 97 Measurement of Radon and Radon Daughters in Air (1988) 99 Quality Assurance for Diagnostic Imaging (1988) 100 Exposure of the U.S. Population from Diagnostic Medical Radiation (1989) 101 Exposure of the U.S. Population from Occupational Radiation (1989) 102 Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use) (1989) 103 Control of Radon in Houses (1989) 104 The Relative Biological Effectiveness of Radiations of Different Quality (1990) 105 Radiation Protection for Medical and Allied Health Personnel (1989) 106 Limit for Exposure to “Hot Particles” on the Skin (1989) 107 Implementation of the Principle of As Low As Reasonably Achievable (ALARA) for Medical and Dental Personnel (1990) 108 Conceptual Basis for Calculations of Absorbed-Dose Distributions (1991) 109 Effects of Ionizing Radiation on Aquatic Organisms (1991) 110 Some Aspects of Strontium Radiobiology (1991) 111 Developing Radiation Emergency Plans for Academic, Medical or Industrial Facilities (1991) 112 Calibration of Survey Instruments Used in Radiation Protection for the Assessment of Ionizing Radiation Fields and Radioactive Surface Contamination (1991) 113 Exposure Criteria for Medical Diagnostic Ultrasound: I. Criteria Based on Thermal Mechanisms (1992) 114 Maintaining Radiation Protection Records (1992) 115 Risk Estimates for Radiation Protection (1993) 116 Limitation of Exposure to Ionizing Radiation (1993)

106 / NCRP PUBLICATIONS 117 Research Needs for Radiation Protection (1993) 118 Radiation Protection in the Mineral Extraction Industry (1993) 119 A Practical Guide to the Determination of Human Exposure to Radiofrequency Fields (1993) 120 Dose Control at Nuclear Power Plants (1994) 121 Principles and Application of Collective Dose in Radiation Protection (1995) 122 Use of Personal Monitors to Estimate Effective Dose Equivalent and Effective Dose to Workers for External Exposure to Low-LET Radiation (1995) 123 Screening Models for Releases of Radionuclides to Atmosphere, Surface Water, and Ground (1996) 124 Sources and Magnitude of Occupational and Public Exposures from Nuclear Medicine Procedures (1996) 125 Deposition, Retention and Dosimetry of Inhaled Radioactive Substances (1997) 126 Uncertainties in Fatal Cancer Risk Estimates Used in Radiation Protection (1997) 127 Operational Radiation Safety Program (1998) 128 Radionuclide Exposure of the Embryo/Fetus (1998) 129 Recommended Screening Limits for Contaminated Surface Soil and Review of Factors Relevant to Site-Specific Studies (1999) 130 Biological Effects and Exposure Limits for “Hot Particles” (1999) 131 Scientific Basis for Evaluating the Risks to Populations from Space Applications of Plutonium (2001) 132 Radiation Protection Guidance for Activities in Low-Earth Orbit (2000) 133 Radiation Protection for Procedures Performed Outside the Radiology Department (2000) 134 Operational Radiation Safety Training (2000) 135 Liver Cancer Risk from Internally-Deposited Radionuclides (2001) 136 Evaluation of the Linear-Nonthreshold Dose-Response Model for Ionizing Radiation (2001) 137 Fluence-Based and Microdosimetric Event-Based Methods for Radiation Protection in Space (2001) 138 Management of Terrorist Events Involving Radioactive Material (2001) 139 Risk-Based Classification of Radioactive and Hazardous Chemical Wastes (2002) 140 Exposure Criteria for Medical Diagnostic Ultrasound: II. Criteria Based on all Known Mechanisms (2002) 141 Managing Potentially Radioactive Scrap Metal (2002) 142 Operational Radiation Safety Program for Astronauts in Low-Earth Orbit: A Basic Framework (2002) 143 Management Techniques for Laboratories and Other Small Institutional Generators to Minimize Off-Site Disposal of Low-Level Radioactive Waste (2003) 144 Radiation Protection for Particle Accelerator Facilities (2003) 145 Radiation Protection in Dentistry (2003)

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146 Approaches to Risk Management in Remediation of Radioactively Contaminated Sites (2004) 147 Structural Shielding Design for Medical X-Ray Imaging Facilities (2004) 148 Radiation Protection in Veterinary Medicine (2004) 149 A Guide to Mammography and Other Breast Imaging Procedures (2004) 150 Extrapolation of Radiation-Induced Cancer Risks from Nonhuman Experimental Systems to Humans (2005) 151 Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities (2005) 152 Performance Assessment of Near-Surface Facilities for Disposal of Low-Level Radioactive Waste (2005) 153 Information Needed to Make Radiation Protection Recommendations for Space Missions Beyond Low-Earth Orbit (2006) 154 Cesium-137 in the Environment: Radioecology and Approaches to Assessment and Management (2006) 155 Management of Radionuclide Therapy Patients (2006) 156 Development of a Biokinetic Model for Radionuclide-Contaminated Wounds and Procedures for Their Assessment, Dosimetry and Treatment (2006) 157 Radiation Protection in Educational Institutions (2007) 158 Uncertainties in the Measurement and Dosimetry of External Radiation (2007) 159 Risk to the Thyroid from Ionizing Radiation (2008) 160 Ionizing Radiation Exposure of the Population of the United States (2009) 161 Management of Persons Contaminated with Radionuclides (2008) 162 Self Assessment of Radiation-Safety Programs (2009) Binders for NCRP reports are available. Two sizes make it possible to collect into small binders the “old series” of reports (NCRP Reports Nos. 8–30) and into large binders the more recent publications (NCRP Reports Nos. 32–162). Each binder will accommodate from five to seven reports. The binders carry the identification “NCRP Reports” and come with label holders which permit the user to attach labels showing the reports contained in each binder. The following bound sets of NCRP reports are also available: Volume I. NCRP Reports Nos. 8, 22 Volume II. NCRP Reports Nos. 23, 25, 27, 30 Volume III. NCRP Reports Nos. 32, 35, 36, 37 Volume IV. NCRP Reports Nos. 38, 40, 41 Volume V. NCRP Reports Nos. 42, 44, 46 Volume VI. NCRP Reports Nos. 47, 49, 50, 51 Volume VII. NCRP Reports Nos. 52, 53, 54, 55, 57 Volume VIII. NCRP Report No. 58 Volume IX. NCRP Reports Nos. 59, 60, 61, 62, 63 Volume X. NCRP Reports Nos. 64, 65, 66, 67 Volume XI. NCRP Reports Nos. 68, 69, 70, 71, 72 Volume XII. NCRP Reports Nos. 73, 74, 75, 76

108 / NCRP PUBLICATIONS Volume XIII. NCRP Reports Nos. 77, 78, 79, 80 Volume XIV. NCRP Reports Nos. 81, 82, 83, 84, 85 Volume XV. NCRP Reports Nos. 86, 87, 88, 89 Volume XVI. NCRP Reports Nos. 90, 91, 92, 93 Volume XVII. NCRP Reports Nos. 94, 95, 96, 97 Volume XVIII. NCRP Reports Nos. 98, 99, 100 Volume XIX. NCRP Reports Nos. 101, 102, 103, 104 Volume XX. NCRP Reports Nos. 105, 106, 107, 108 Volume XXI. NCRP Reports Nos. 109, 110, 111 Volume XXII. NCRP Reports Nos. 112, 113, 114 Volume XXIII. NCRP Reports Nos. 115, 116, 117, 118 Volume XXIV. NCRP Reports Nos. 119, 120, 121, 122 Volume XXV. NCRP Report No. 123I and 123II Volume XXVI. NCRP Reports Nos. 124, 125, 126, 127 Volume XXVII. NCRP Reports Nos. 128, 129, 130 Volume XXVIII. NCRP Reports Nos. 131, 132, 133 Volume XXIX. NCRP Reports Nos. 134, 135, 136, 137 Volume XXX. NCRP Reports Nos. 138, 139 Volume XXXI. NCRP Report No. 140 Volume XXXII. NCRP Reports Nos. 141, 142, 143 Volume XXXIII. NCRP Report No. 144 Volume XXXIV. NCRP Reports Nos. 145, 146, 147 Volume XXXV. NCRP Reports Nos. 148, 149 Volume XXXVI. NCRP Reports Nos. 150, 151, 152 Volume XXXVII, NCRP Reports Nos. 153, 154, 155 Volume XXXVIII, NCRP Reports Nos. 156, 157, 158 (Titles of the individual reports contained in each volume are given previously.)

NCRP Commentaries No.

Title 1

4

5 6 7 8 9 10

Krypton-85 in the Atmosphere—With Specific Reference to the Public Health Significance of the Proposed Controlled Release at Three Mile Island (1980) Guidelines for the Release of Waste Water from Nuclear Facilities with Special Reference to the Public Health Significance of the Proposed Release of Treated Waste Waters at Three Mile Island (1987) Review of the Publication, Living Without Landfills (1989) Radon Exposure of the U.S. Population—Status of the Problem (1991) Misadministration of Radioactive Material in Medicine—Scientific Background (1991) Uncertainty in NCRP Screening Models Relating to Atmospheric Transport, Deposition and Uptake by Humans (1993) Considerations Regarding the Unintended Radiation Exposure of the Embryo, Fetus or Nursing Child (1994) Advising the Public about Radiation Emergencies: A Document for Public Comment (1994)

NCRP PUBLICATIONS

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Dose Limits for Individuals Who Receive Exposure from Radionuclide Therapy Patients (1995) Radiation Exposure and High-Altitude Flight (1995) An Introduction to Efficacy in Diagnostic Radiology and Nuclear Medicine (Justification of Medical Radiation Exposure) (1995) A Guide for Uncertainty Analysis in Dose and Risk Assessments Related to Environmental Contamination (1996) Evaluating the Reliability of Biokinetic and Dosimetric Models and Parameters Used to Assess Individual Doses for Risk Assessment Purposes (1998) Screening of Humans for Security Purposes Using Ionizing Radiation Scanning Systems (2003) Pulsed Fast Neutron Analysis System Used in Security Surveillance (2003) Biological Effects of Modulated Radiofrequency Fields (2003) Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (2005) Radiation Protection and Measurement Issues Related to Cargo Scanning with Accelerator-Produced High-Energy X Rays (2007)

Proceedings of the Annual Meeting No.

Title 1 3

4

5

6

7 8

9

10 11

Perceptions of Risk, Proceedings of the Fifteenth Annual Meeting held on March 14-15, 1979 (including Taylor Lecture No. 3) (1980) Critical Issues in Setting Radiation Dose Limits, Proceedings of the Seventeenth Annual Meeting held on April 8-9, 1981 (including Taylor Lecture No. 5) (1982) Radiation Protection and New Medical Diagnostic Approaches, Proceedings of the Eighteenth Annual Meeting held on April 6-7, 1982 (including Taylor Lecture No. 6) (1983) Environmental Radioactivity, Proceedings of the Nineteenth Annual Meeting held on April 6-7, 1983 (including Taylor Lecture No. 7) (1983) Some Issues Important in Developing Basic Radiation Protection Recommendations, Proceedings of the Twentieth Annual Meeting held on April 4-5, 1984 (including Taylor Lecture No. 8) (1985) Radioactive Waste, Proceedings of the Twenty-First Annual Meeting held on April 3-4, 1985 (including Taylor Lecture No. 9)(1986) Nonionizing Electromagnetic Radiations and Ultrasound, Proceedings of the Twenty-Second Annual Meeting held on April 2-3, 1986 (including Taylor Lecture No. 10) (1988) New Dosimetry at Hiroshima and Nagasaki and Its Implications for Risk Estimates, Proceedings of the Twenty-Third Annual Meeting held on April 8-9, 1987 (including Taylor Lecture No. 11) (1988) Radon, Proceedings of the Twenty-Fourth Annual Meeting held on March 30-31, 1988 (including Taylor Lecture No. 12) (1989) Radiation Protection Today—The NCRP at Sixty Years, Proceedings of the Twenty-Fifth Annual Meeting held on April 5-6, 1989 (including Taylor Lecture No. 13) (1990)

110 / NCRP PUBLICATIONS 12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Health and Ecological Implications of Radioactively Contaminated Environments, Proceedings of the Twenty-Sixth Annual Meeting held on April 4-5, 1990 (including Taylor Lecture No. 14) (1991) Genes, Cancer and Radiation Protection, Proceedings of the Twenty-Seventh Annual Meeting held on April 3-4, 1991 (including Taylor Lecture No. 15) (1992) Radiation Protection in Medicine, Proceedings of the Twenty-Eighth Annual Meeting held on April 1-2, 1992 (including Taylor Lecture No. 16) (1993) Radiation Science and Societal Decision Making, Proceedings of the Twenty-Ninth Annual Meeting held on April 7-8, 1993 (including Taylor Lecture No. 17) (1994) Extremely-Low-Frequency Electromagnetic Fields: Issues in Biological Effects and Public Health, Proceedings of the Thirtieth Annual Meeting held on April 6-7, 1994 (not published). Environmental Dose Reconstruction and Risk Implications, Proceedings of the Thirty-First Annual Meeting held on April 12-13, 1995 (including Taylor Lecture No. 19) (1996) Implications of New Data on Radiation Cancer Risk, Proceedings of the Thirty-Second Annual Meeting held on April 3-4, 1996 (including Taylor Lecture No. 20) (1997) The Effects of Pre- and Postconception Exposure to Radiation, Proceedings of the Thirty-Third Annual Meeting held on April 2-3, 1997, Teratology 59, 181–317 (1999) Cosmic Radiation Exposure of Airline Crews, Passengers and Astronauts, Proceedings of the Thirty-Fourth Annual Meeting held on April 1-2, 1998, Health Phys. 79, 466–613 (2000) Radiation Protection in Medicine: Contemporary Issues, Proceedings of the Thirty-Fifth Annual Meeting held on April 7-8, 1999 (including Taylor Lecture No. 23) (1999) Ionizing Radiation Science and Protection in the 21st Century, Proceedings of the Thirty-Sixth Annual Meeting held on April 5-6, 2000, Health Phys. 80, 317–402 (2001) Fallout from Atmospheric Nuclear Tests—Impact on Science and Society, Proceedings of the Thirty-Seventh Annual Meeting held on April 4-5, 2001, Health Phys. 82, 573–748 (2002) Where the New Biology Meets Epidemiology: Impact on Radiation Risk Estimates, Proceedings of the Thirty-Eighth Annual Meeting held on April 10-11, 2002, Health Phys. 85, 1–108 (2003) Radiation Protection at the Beginning of the 21st Century–A Look Forward, Proceedings of the Thirty-Ninth Annual Meeting held on April 9–10, 2003, Health Phys. 87, 237–319 (2004) Advances in Consequence Management for Radiological Terrorism Events, Proceedings of the Fortieth Annual Meeting held on April 14–15, 2004, Health Phys. 89, 415–588 (2005) Managing the Disposition of Low-Activity Radioactive Materials, Proceedings of the Forty-First Annual Meeting held on March 30–31, 2005, Health Phys. 91, 413–536 (2006) Chernobyl at Twenty, Proceedings of the Forty-Second Annual Meeting held on April 3–4, 2006, Health Phys. 93, 345–595 (2007)

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Advances in Radiation Protection in Medicine, Proceedings of the Forty-Third Annual Meeting held on April 16-17, 2007, Health Phys. 95, 461–686 (2008) Low Dose and Low Dose-Rate Radiation Effects and Models, Proceedings of the Forty-Fourth Annual Meeting held on April 14–15, 2008, Health Phys. 97, 373–541 (2009)

Lauriston S. Taylor Lectures No.

Title 1 2 3 4 5

6

7

8

9 10

11

12 13

14

15

The Squares of the Natural Numbers in Radiation Protection by Herbert M. Parker (1977) Why be Quantitative about Radiation Risk Estimates? by Sir Edward Pochin (1978) Radiation Protection—Concepts and Trade Offs by Hymer L. Friedell (1979) [available also in Perceptions of Risk, see above] From “Quantity of Radiation” and “Dose” to “Exposure” and “Absorbed Dose”—An Historical Review by Harold O. Wyckoff (1980) How Well Can We Assess Genetic Risk? Not Very by James F. Crow (1981) [available also in Critical Issues in Setting Radiation Dose Limits, see above] Ethics, Trade-offs and Medical Radiation by Eugene L. Saenger (1982) [available also in Radiation Protection and New Medical Diagnostic Approaches, see above] The Human Environment—Past, Present and Future by Merril Eisenbud (1983) [available also in Environmental Radioactivity, see above] Limitation and Assessment in Radiation Protection by Harald H. Rossi (1984) [available also in Some Issues Important in Developing Basic Radiation Protection Recommendations, see above] Truth (and Beauty) in Radiation Measurement by John H. Harley (1985) [available also in Radioactive Waste, see above] Biological Effects of Non-ionizing Radiations: Cellular Properties and Interactions by Herman P. Schwan (1987) [available also in Nonionizing Electromagnetic Radiations and Ultrasound, see above] How to be Quantitative about Radiation Risk Estimates by Seymour Jablon (1988) [available also in New Dosimetry at Hiroshima and Nagasaki and its Implications for Risk Estimates, see above] How Safe is Safe Enough? by Bo Lindell (1988) [available also in Radon, see above] Radiobiology and Radiation Protection: The Past Century and Prospects for the Future by Arthur C. Upton (1989) [available also in Radiation Protection Today, see above] Radiation Protection and the Internal Emitter Saga by J. Newell Stannard (1990) [available also in Health and Ecological Implications of Radioactively Contaminated Environments, see above] When is a Dose Not a Dose? by Victor P. Bond (1992) [available also in Genes, Cancer and Radiation Protection, see above]

112 / NCRP PUBLICATIONS 16

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Dose and Risk in Diagnostic Radiology: How Big? How Little? by Edward W. Webster (1992) [available also in Radiation Protection in Medicine, see above] Science, Radiation Protection and the NCRP by Warren K. Sinclair (1993) [available also in Radiation Science and Societal Decision Making, see above] Mice, Myths and Men by R.J. Michael Fry (1995) Certainty and Uncertainty in Radiation Research by Albrecht M. Kellerer. Health Phys. 69, 446–453 (1995) 70 Years of Radiation Genetics: Fruit Flies, Mice and Humans by Seymour Abrahamson. Health Phys. 71, 624–633 (1996) Radionuclides in the Body: Meeting the Challenge by William J. Bair. Health Phys. 73, 423–432 (1997) From Chimney Sweeps to Astronauts: Cancer Risks in the Work Place by Eric J. Hall. Health Phys. 75, 357–366 (1998) Back to Background: Natural Radiation and Radioactivity Exposed by Naomi H. Harley. Health Phys. 79, 121–128 (2000) Administered Radioactivity: Unde Venimus Quoque Imus by S. James Adelstein. Health Phys. 80, 317–324 (2001) Assuring the Safety of Medical Diagnostic Ultrasound by Wesley L. Nyborg. Health Phys. 82, 578–587 (2002) Developing Mechanistic Data for Incorporation into Cancer and Genetic Risk Assessments: Old Problems and New Approaches by R. Julian Preston. Health Phys. 85, 4–12 (2003) The Evolution of Radiation Protection–From Erythema to Genetic Risks to Risks of Cancer to ? by Charles B. Meinhold, Health Phys. 87, 240–248 (2004) Radiation Protection in the Aftermath of a Terrorist Attack Involving Exposure to Ionizing Radiation by Abel J. Gonzalez, Health Phys. 89, 418–446 (2005) Nontargeted Effects of Radiation: Implications for Low Dose Exposures by John B. Little, Health Phys. 91, 416–426 (2006) Fifty Years of Scientific Research: The Importance of Scholarship and the Influence of Politics and Controversy by Robert L. Brent, Health Phys. 93, 348–379 (2007) The Quest for Therapeutic Actinide Chelators by Patricia W. Durbin, Health Phys. 95, 465–492 (2008) Yucca Mountain Radiation Standards, Dose/Risk Assessments, Thinking Outside the Box, Evaluations, and Recommendations by Dade W. Moeller, Health Phys. 97, 376–391 (2009)

Symposium Proceedings No.

Title 1

2

The Control of Exposure of the Public to Ionizing Radiation in the Event of Accident or Attack, Proceedings of a Symposium held April 27-29, 1981 (1982) Radioactive and Mixed Waste—Risk as a Basis for Waste Classification, Proceedings of a Symposium held November 9, 1994 (1995)

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Acceptability of Risk from Radiation—Application to Human Space Flight, Proceedings of a Symposium held May 29, 1996 (1997) 21st Century Biodosimetry: Quantifying the Past and Predicting the Future, Proceedings of a Symposium held February 22, 2001, Radiat. Prot. Dosim. 97(1), (2001) National Conference on Dose Reduction in CT, with an Emphasis on Pediatric Patients, Summary of a Symposium held November 6-7, 2002, Am. J. Roentgenol. 181(2), 321–339 (2003)

NCRP Statements No.

Title 1 2

3

4

5 6 7 8 9 10

“Blood Counts, Statement of the National Committee on Radiation Protection,” Radiology 63, 428 (1954) “Statements on Maximum Permissible Dose from Television Receivers and Maximum Permissible Dose to the Skin of the Whole Body,” Am. J. Roentgenol., Radium Ther. and Nucl. Med. 84, 152 (1960) and Radiology 75, 122 (1960) X-Ray Protection Standards for Home Television Receivers, Interim Statement of the National Council on Radiation Protection and Measurements (1968) Specification of Units of Natural Uranium and Natural Thorium, Statement of the National Council on Radiation Protection and Measurements (1973) NCRP Statement on Dose Limit for Neutrons (1980) Control of Air Emissions of Radionuclides (1984) The Probability That a Particular Malignancy May Have Been Caused by a Specified Irradiation (1992) The Application of ALARA for Occupational Exposures (1999) Extension of the Skin Dose Limit for Hot Particles to Other External Sources of Skin Irradiation (2001) Recent Applications of the NCRP Public Dose Limit Recommendation for Ionizing Radiation (2004)

Other Documents The following documents were published outside of the NCRP report, commentary and statement series: Somatic Radiation Dose for the General Population, Report of the Ad Hoc Committee of the National Council on Radiation Protection and Measurements, 6 May 1959, Science 131 (3399), February 19, 482–486 (1960) Dose Effect Modifying Factors in Radiation Protection, Report of Subcommittee M-4 (Relative Biological Effectiveness) of the National Council on Radiation Protection and Measurements, Report BNL 50073 (T-471) (1967) Brookhaven National Laboratory (National Technical Information Service, Springfield, Virginia) Residential Radon Exposure and Lung Cancer Risk: Commentary on Cohen's County-Based Study, Health Phys. 87(6), 656–658 (2004)

Index Corrective-action plans 2, 42, 44–45, 59, 64–65 Corrective-action tracking system 63–66

Accelerators 5, 10, 12, 39–40, 75–76, 79, 82 Access control 35, 76, 78–79 Accidents 4–5, 9, 12, 21, 26, 31, 41, 51 Agreement States 5, 12, 41, 83 Air monitoring 79–80 Air sampling 9, 34, 79 Alarms 44–45, 74, 76, 78–80, 84 American Board of Health Physics 29, 74 American Board of Medical Physics 29, 74 American Board of Radiology 29, 74 Area monitoring 34, 80 As low as reasonably achievable (ALARA) 5, 8–9, 12, 22, 45, 74–76, 85 Audits 1, 3–4, 18, 26, 31, 48, 50–52, 76, 84 corrective actions 50 engineered safety controls 76 external auditor 31 physical controls 84

Deficiencies 41–45, 63–66 immediate response 44–45 prompt response 43–44 routine response 42 timely response 43 tracking system 63–65 Dental x-ray technicians 73–75 Department of Energy (DOE) 4–6, 12, 17, 23, 39–41, 44, 64, 75, 77–79 accelerators 39–40, 79 accidents 4 ALARA 5, 75 fume hoods 78 glove boxes 78 Integrated Safety Management Program 6 listed quantities 44 quality management 6 reporting 41 root-cause analysis 64 self assessments 17, 23 ventilation 77 Department of Transportation (DOT) 5, 12 Derived air concentration 44 Disposal 15, 35–36, 83, 86–87 sources 15, 83 waste 35–36, 86–87 Dose limits 28, 39, 43, 76 Dosimeters 9, 13–14, 37

Bioassay 52, 79 Calibration 34, 40, 42–43, 81 Causal analysis 25, 58, 64 Certification 27, 29, 31, 74, 81 Checklists 2, 4, 18, 34, 38–40, 48, 50, 56, 58, 60 use of 38–39 Contamination control 15, 23, 46 Continuous improvement 6–7, 10, 13, 17, 31, 42, 45, 59, 66, 85

Effluents 11, 22, 34, 77, 85–86

114

INDEX

Emergencies 7–9, 11–12, 15, 23, 36, 39, 73–74, 79, 82 power 15 preparedness 82 responders 73 response exercises 9, 12, 23, 36 shutdown switches 79 Environmental Protection Agency (EPA) 5, 12, 17, 41, 61 Environmental radiation 85–86 Filters 11 Fissile material 45 Food and Drug Administration (FDA) 5, 12 Fume hoods 78 Glove boxes 13–15, 73–74, 76–78, 80 Hot particles 23 Human factors 64 Independent consultants 24, 33, 58 In-house personnel 32–33 Interlocks 11, 38, 43, 45, 79 International Atomic Energy Agency (IAEA) 6 International Organization for Standardization 6 Interviews 36–38, 67–70 on communications 67 on facility issues 68 on management and supervision 70 on training 69–70 on written documents 67–68 on work and supervision 69 on work practices 68–69 Inventories 14–15, 39, 46, 82–84, 87 Leak tests 39, 43, 82–83 Licensees 83–84

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Licenses 5, 12, 23, 30, 38–39, 51, 74, 83 Mine Safety and Health Administration (MSHA) 5, 12 Mixed waste 46 Near misses 9, 12, 21, 23, 52, 54 Noncompliance 6, 22, 41, 52, 59, 61, 63 Nonradiological hazards 45 Noteworthy practices 2, 7, 41–42, 45–46, 56, 58–60 Nuclear fuel 3, 49, 82 Nuclear medicine 10, 30, 74 Nuclear power 1, 3, 10, 15, 49, 53, 73, 75, 82 Nuclear Regulatory Commission (NRC) 4–6, 12, 17, 23–24, 41–42, 44, 64, 75, 83 accidents 4 ALARA 5, 75 causal analysis 64 listed quantities 44, 83 reporting 41 respirators 42 safety-conscious environment 6 self assessments 17, 23–24 Occupational Safety and Health Administration (OSHA) 5, 12, 17, 41 Offsite exposure 85 Outside contractors 33 Performance improvement 20, 25–26, 61 Performance measures 4, 9, 25, 40, 51–52, 58–60, 65 Photographs 36, 58 Pregnancy 37 Property damage 43–45 Proprietary information 36, 47, 62 Protective equipment 9, 15, 23, 35, 42, 80

116 / INDEX Qualifications 9, 25, 27–33, 47, 54, 60, 71–75 assessors 27–31, 47, 75 experience 28, 30–31, independence and access 31 instructors 71 knowledge of area 28–29, 31 nonprofessional personnel 30 staff 9, 25, 28 team members 54, 60 training and certification 29–31 workers 71–72 Quality 6, 8, 20, 27, 40, 47–48, 52, 57, 59–61, 64–65, 84 assurance 20, 52, 57, 60–61, 84 control 40, 52, 64 improvement 6 management 6 of correction actions 59, 65 of self assessment 27, 47–48 of staff 8 of training 8 Questionnaires 2, 37, 56 Radiation alarms 78–79 Radiation-generating equipment 9, 15, 23, 38, 82–83 Radiation monitoring 34–35 Radiation safety committee (RSC) 1, 18, 23, 34, 47, 61 Radiation safety officer (RSO) 1, 18, 23, 34, 73 Radiation therapy 23, 76 Radioactive sources 1, 11, 82–84 accountability and control 82–84 Radioactive waste 13–15, 22, 35–36, 38, 86–87 containers 13 control 22 disposal 35–36 legacy waste 86–87 management 15, 86–87 processing 36 storage 14 types 38 Radiographers 73–74, 83

Radiologists 73 Records 87 Regulations 3–8, 10, 12–14, 16–17, 30, 51, 62, 66, 74, 83 Regulators 1, 3, 7, 22, 57, 61, 63 Regulatory agency 12, 17, 22–23, 40, 48 Research reactors 43 Respirators 15, 23, 35, 42 Root causes 42–45, 62, 64–65 Safety culture 6, 9, 17 Sealed sources 15, 43, 46, 82–83 Security 10, 15, 23, 35, 38, 46–47, 52, 73–74, 82–84 limitations 47, 52 personnel 73–74 physical 83–84 sources 15, 23, 35, 38, 46, 82 Self assessments 3–7, 8–16, 71–87 access control 78–79 adequacy of equipment 80–81 air monitoring 79–80 ALARA program 74–76 compliance based 12–13 definition 3–4 emergency preparedness 82 environmental radiation 85–86 formal 15–16 fume hoods 78 glove boxes 78 informal 15–16 performance based 8–10 process level 14 program level 14–15 purpose 4–7 radiation alarms 78–79 radioactive waste 86–87 records 87 risk based 10–12 shielding 76–77 software 84 source accountability and control 82–84 task level 13–14 ventilation and filtration 77

INDEX

worker attitude 85 worker qualifications 72–74 worker training 71–72 Self assessments (conduct of) 53–56 briefing agenda 53–54 documentation 55–56 entrance meeting 53 exit meeting 55 management briefings 55 team conferences 54–55 Self assessments (documentation) 57–62 communication of results 61 legal considerations 61–62 reports to regulators 61 written reports 57–60 Self assessments (methods, techniques) 34–40 checklists 38–40 documentation 40 document review 40 interviews 36–38 radiation monitoring 34–35 workplace observations 35–36 Self assessments (planning) 20–26, 47–52 coordination 52 criteria 51–52 focus 49 objectives 20 program elements 22–23 resources 24–25 review 25–26 schedule 23–24, 48 tasks 48–49 team leader 50–51 team members 51 tools 49 types of assessments 20–22 Self assessments (responsibilities) 17–19 institutional managers 17 line managers 18 radiation safety officer (RSO) 18–19 workers 19

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Shielding 10, 22, 35, 40, 43, 76–78, 80–81, 84–85 adequacy 76–77, 80 codes 84 design 22 devices 35 fume hoods 78 glove boxes 78 permanent 76, 80 policy 40 requirements 10 temporary 76, 81 use 35 Signs 35, 74, 79 Skin contamination 37 Skyshine radiation 77 Software 84 counting systems 84 dispersion codes 84 dose calculations 84 inventory programs 84 shielding codes 84 Special nuclear material 44, 82 Standards 3, 6, 11, 45, 51, 57–59, 62, 70, 75, 81 Storage 11, 14–15, 35, 43, 46, 86–87 food 43 records 46, 87 sources 11, 15, 35 waste 14, 86 Survey instruments 11, 14, 25, 39, 81 Swipe surveys 9, 34 Team leader 49–51, 54–55, 60 responsibilities 50–51 Team members 50–51, 53–56, 60 qualifications 54, 60 responsibilities 51 Technicians 21, 31, 72–74 Temporary shielding 76–77, 81 Tracking system 63–66 Trending 25–26, 35, 59, 61 Uncontrolled release 45–46

118 / INDEX Unsealed sources 42, 82 Unsecured access 44 Ventilation 15, 35, 43, 76–78, 80, 85 Warning lights 79 Warning signs 79 Waste management 8, 10, 15, 85–86

Waste-retention tank 11, 21 Worker attitude 85 Worker qualifications 72–74 general workers 73 managers and supervisors 73 radiation-safety personnel 72–73 radiation workers 73 Worker training 71–72 X-ray machines 5, 12, 38, 82